Every finding on record at Columbus Alzheimer's Care CTR

Based on observations, staff interview, and review of facility policies, the facility failed to store food and wash dishes in a safe and sanitary manner. This had the potential to affect all 99 residents in the facility who ate food from the kitchen. The facility census was 99 residents.1. Observations in the dry storage room on 07/06/26 at 8:51 A.M. revealed individual servings of sweet and sour sauce were labeled as opened on 06/06/26 and use by 06/26/26. Observations in the walk-in refrigerator on 07/06/26 at 8:58 A.M. revealed the following concerns:-A tray of diced peppers labeled best by 06/30/26.-A 5 pound tub of sour cream, opened and partially full with no open date. -An opened, partially full, 25-pound tub of hard-boiled eggs with a delivery date of 06/11/26 and no open date.An interview with Dietary Director #240 on 07/06/26 at 9:10 A.M. confirmed the above findings. Review of the facility policy dated 08/21/23 titled, Food Storage, revealed that goods that have been opened with no date will be discarded. All outdated goods will be discarded the day after expiration. 2. Observations on 07/06/26 at 10:10 A.M. revealed the facility staff were washing the residents' breakfast dishes. Observations on 07/06/26 at 10:17 A.M. and 10:19 A.M. revealed the dishwashing machine was registering less that 50 parts per million on the chlorine test strips for the final rinse cycle. An interview with Dietary Director on 07/06/26 at 10:19 A.M. confirmed that the dishwasher was not reaching 50 parts per million on the chlorine sanitation test strips. Review of the undated facility policy titled, Machine Washing and Sanitizing, revealed that the final rinse will have a 50 parts per million chlorine.

Based on record review, observation, interviews, and review of facility policy, the facility failed to properly store medication for Resident #82. This affected one resident (#82) and had the potential to affect 40 independently mobile residents on the memory care unit (#7, #11, #13, #17, #23, #27, #29, #33, #35, #37, #39, #42, #43, #44, #46, #48, #49, #50, #51, #53, #58, #60, #61, #62, #66, #67, #71, #73, #74, #75, #80, #82, #84, #85, #87, #89, #90, #93, #94, and #97). Additionally, the facility failed to ensure two out of three medication carts were maintained without loose medications. This had the potential to affect 61 residents (#4, #6, #7, #9, #11, #12, #13, #15, #16, #17, #23, #25, #26, #27, #29, #30, #33, #35, #37, #39, #42, #43, #44, #46, #47, #48, #49, #50, #51, #53, #56, #57, #58, #60, #61, #62, #63, #65, #66, #67, #69, #70, #71, #73, #74, #75, #76, #80, #82, #83, #84, #85, #87, #88, #89, #90, #91, #93, #94, #95, and #97), whose medications were included in carts #1 and #2. The facility census was 99.Findings include: 1. Observation and interview on 07/09/26 at 11:24 A.M. with Assistant Director of Nursing (ADON) #200 identified 11 whole pills, one half pill, and two quarter pills found in cart #1 drawer #2. The pills were identified/observed as white round pill with ll on it (identified as olanzapine 2.5 mg), two orange round pills with 277 on it (identified as aspirin), grey oval pill with m10 on it (identified as memantine hydrochloride 10 mg), three red circle pills with 50 on it (unidentifiable), two white round pills with 171u on it (identified as memantine hydrochloride 5 mg), one white round pill with u10 on it (identified as amlodipine besylate 10 mg), yellow round pill with f57 on it (unidentifiable), one half pill (unidentifiable), and two quarter pills (unidentifiable). The ADON reported routine cleaning of the carts should be conducted to prevent accumulation of loose medications found underneath the medication cards. Interview on 07/09/26 at 11:32 A.M. with Registered Nurse (RN) #275 revealed RN #275 denied conducting routine cleaning of the medication cart. Interview on 07/09/26 at 11:44 A.M. with Licensed Practical Nurse (LPN) #207 confirmed that upon possession of the cart, cleaning was conducted by the nurse. 2. Observation and interview on 07/09/26 at 11:49 A.M. with ADON #200 identified five loose pills in cart #3 drawer #2. The pills were identified as one red round pill with f50 on it (unidentifiable), one oval red pill with 894 on it (identified as Eliquis 5 mg), one grey oblong pill with m10 on it (identified as memantine 10 mg), and two tan pills with f49 on it (identified as galantamine hydrobromide 4 mg). Review of the medication storage policy, undated, revealed medications will be stored in the original, labeled containers received from the pharmacy, and medications will be stored in an orderly, organized manner in a clean area. 3. Medical record review for Resident #82 revealed an admission date 03/27/25 with diagnoses of Alzheimer's disease with late onset, muscle weakness and dementia in other diseases classified elsewhere moderate, with anxiety. Review of the Self-Administration of Medication assessment dated [DATE] revealed Resident #82 was not capable of administering her own medication. Review of the Secured Unit assessment dated [DATE] revealed Resident #82 required dementia-related care in a secured area for safety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 08, indicating the resident had moderate cognitive impairment. Review of Resident #82's physician orders and Medication Administration Record (MAR) revealed the resident was to receive the following medications at 8:00 A.M. and 9:00 A.M.: Amlodipine 10 milligrams (mg), Folic Acid 1 mg, Losartan Potassium 50 mg (with instructions to give 1.5 tablets), Magnesium Oxide 400 mg, Multivitamin, Thiamine 100 mg, Vitamin C, Zoloft 50 mg, Ferrous sulfate 325 mg, Galantamine 4 mg, Memantine 5 mg (with instructions to give two tablets), Neurontin 100 mg, and Tramadol 50 mg. Observation on 07/07/26 at 8:26 A.M. revealed unsupervised medication in a plastic cup placed on the nightstand next to Resident #82's bed. Interview on 07/07/26 at 8:28 A.M. with LPN #208 confirmed medication on the nightstand was morning medications for Resident #82. LPN #208 administered the medication to Resident #82 at that time. Review of the undated facility policy titled Policy-5.0 Medication Storage revealed with the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart of medication room that is accessible only to authorized personnel, as defined by facility policy.

Based on observation, interview, record review, and review of manufacture guidelines, the facility failed to ensure insulin was primed prior to administration. This affected one (Resident #3) out of three residents observed for medication administration. The facility census was 99. Findings include:Review of the medical record for Resident #3 revealed an admission date of 07/09/24 with diagnoses of encephalopathy, Alzheimer's disease, diabetes mellitus, and acute kidney failure.Review of the care plan dated 07/24/25 revealed the resident had diabetes mellitus, with interventions including completing blood sugar checks as ordered by the physician and administering medication as prescribed.Review of the annual Minimum Data Set (MDS) 3.0 assessment completed 06/30/26 revealed Resident #3 was severely cognitively impaired and required insulin injections seven days a week.Review of the physician order dated 07/07/26 revealed orders for insulin aspart subcutaneous solution pen injector 100 units/milliliter to be administered according to sliding scale before meals: 80-199 = 0 units (notify physician if below 80); 200-250 = 4 units; 251-300 = 6 units; 301-350 = 10 units; 351-400 = 12 units; 401-450 = 14 units; and 451-500 = 16 units.Review of the vital signs summary labeled blood sugar results dated 07/08/26 at 11:29 A.M. revealed a blood sugar of 331 milligrams per deciliter (mg/dl).Review of the medication administration record (MAR) dated 07/08/26 revealed an administration of 10 units of insulin.Observation of insulin administration on 07/08/26 at 11:29 A.M. with Licensed Practical Nurse (LPN) #252 revealed the nurse obtained the resident's blood sugar measurement of 331 mg/dl and prepared the insulin pen by attaching the needle and dialing the dose to 10 units. The nurse did not perform priming of the insulin pen. The resident was then wheeled to their room, and the insulin was administered without priming.Interview on 07/08/26 at 11:35 A.M. with LPN #252 confirmed priming of the insulin pen was not completed.Interview on 07/08/26 at 11:45 A.M. with the Director of Nursing (DON) revealed the facility did not have an insulin administration policy and instead followed manufacturer guidelines.Interview on 07/08/26 at 3:42 P.M. with the DON confirmed the nurse reported she had not primed the pen and confirmed that the pen must be primed prior to dialing the dose.Review of manufacturer prescribing information for Novolog (insulin aspart) FlexPen revised 02/2023 revealed instructions to select two units, hold the pen with the needle pointing upward, gently tap the top of the pen to raise air bubbles, press and hold the dose button until the dose counter shows 0, and verify a drop of insulin appears at the needle tip prior to use.

Based on review of a resident medical record, observations, staff interviews, and review of facility policy, the facility failed to administer oxygen as ordered for a resident. This affected one resident (#24) out of one resident reviewed for oxygen. The facility census was 99 residents.Findings include:Review of a resident medical record revealed that Resident #24 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease, dementia with mood disturbance, and chronic respiratory failure. Review of Resident #24's physician order dated 09/25/24 revealed that Resident #24 was ordered to have oxygen at 4 liters per minute via nasal canula continually. Review of Resident #24's care plan dated 08/05/25 revealed that Resident #24 had altered respiratory status related to chronic obstructive pulmonary disease. Listed interventions on the care plan included administering medications as ordered and administering oxygen as ordered by the physician. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #24 had a Brief Interview for Mental Status score of 10, indicative of moderate cognitive impairment. Resident #24 was assessed as receiving oxygen. An observation on 07/06/26 at 10:34 A.M. revealed that his oxygen tubing was not on Resident #24's face. The nasal canula was hanging from a dresser pull handle. The oxygen concentrator was running and set at 2 liters per minute. An interview with MDS Coordinator #169 on 07/06/26 at 10:38 A.M. confirmed that Resident #24 was not wearing his oxygen and the concentrator was not set to the correct flow rate. Review of a facility policy dated April 2023 titled, Oxygen Administration, revealed that oxygen is administered with consistent standards of practice, and the comprehensive person-centered care plan. Oxygen is administered under orders of a physician.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure physician ordered wound treatments were documented as completed per physician order. This affected one (Resident #68) out of two residents reviewed for skin management. The facility census was 99. Findings include: Review of the medical record for Resident #68 revealed an admission date of 09/02/21, with diagnoses including Alzheimer's disease, vascular dementia, open wound of the left lower leg, venous insufficiency, cellulitis of the left and right lower limbs, major depressive disorder, psychotic disorder with delusions, generalized anxiety disorder and alcohol dependence.Review of a physician order dated 01/14/25 revealed instructions to apply Altrac tain external cream 10 4% (urea lactic acid) to the left lower extremity (not in wound areas) topically one time daily. The order instructed staff to cleanse the area around the wound bed with soap and water and then apply the cream.Review of the care plan dated 06/02/25 revealed the resident has a behavior problem related to noncompliance and was resistive to care, including resistance to removing leg wound dressings.Review of the care plan dated 07/29/25 revealed the resident had a vascular wound to the left lower extremity related to edema and venous insufficiency. Interventions included completing treatments as ordered, encouraging the resident not to remove the dressing, measuring and recording wound progress, and monitoring wounds until resolved.Review of physician orders dated 02/12/26 revealed wound #1 (left lower extremity lateral venous ulcer) and wound #2 (left lower extremity medial venous ulcer) treatments including the following: apply acetic acid soaks for 5-10 minutes, apply Atractain cream to the periwound, apply crushed Flagyl to the wound bed for autolytic debridement, followed by silicone bordered super absorber, rolled gauze, and compression with Tubi Grip. Treatments were to be performed daily and as needed in the evening.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment, required partial/moderate assistance with lower body dressing, did not exhibit rejection of care, was at risk for pressure injuries, and had two venous or arterial ulcers treated with nonsurgical dressings.Review of a Braden Scale risk assessment revealed the resident had no sensory impairment, was rarely moist, walked frequently, had no mobility limitations, had excellent nutrition, and had no issues with friction or shear, placing the resident at risk for skin impairments.Review of wound assessments dated 04/08/26 revealed wound #1 measured 16 centimeters (cm) by 17 cm with a depth of 0.1 cm (272 sq cm). Wound #2 measured 15 cm by 9 cm with a depth of 0.1 cm (135 sq cm).Review of the Treatment Administration Record (TAR) for 04/01/26 through 04/30/26 revealed Altrac tain cream treatments were not documented as completed or refused on 04/01/26, 04/02/26, 04/03/26, 04/08/26, 04/09/26, 04/10/26, 04/13/26, 04/14/26, 04/16/26, 04/20/26, 04/21/26, 04/22/26, 04/23/26, 04/24/26, and 04/29/26. Wound #1 and wound #2 treatments were not documented as completed or refused on 04/01/26, 04/02/26, 04/03/26, 04/08/26, 04/09/26, 04/10/26, 04/13/26, 04/14/26, 04/15/26, 04/16/26, 04/17/26, 04/20/26, 04/21/26, 04/22/26, 04/23/26, 04/24/26, 04/29/26, and 04/30/26.Review of TAR for 05/01/26 through 05/31/26 revealed Altrac tain cream treatments, wound #1, and wound #2 treatments were not documented as completed or refused on 05/06/26, 05/07/26, 05/12/26, 05/13/26, 05/14/26, 05/15/26, 05/19/26, 05/21/26, 05/26/26, 05/27/26, 05/28/26, and 05/29/26. Review of TAR for 06/01/26 through 06/30/26 revealed Altrac tain cream, wound #1, and wound #2 treatments were not documented as completed or refused on 06/03/26, 06/04/26, 06/10/26, 06/11/26, 06/12/26, 06/17/26, 06/18/26, 06/19/26, 06/24/26, 06/25/26, and 06/26/26.Review of TAR for 07/01/26 through 07/07/26 revealed Altrac tain cream, wound #1, and wound #2 treatments were not documented as completed or refused on 07/02/26.Review of progress notes from 04/01/26 through 07/07/26 revealed missed treatments or refusals were not documented.Review of behavior monitoring from 06/09/26 through 07/07/26 revealed missed wound treatments or refusals were not documented as behavioral symptoms.Interview on 07/08/26 at 3:47 P.M. with Assistant Director of Nursing (ADON) #200 confirmed the resident's medical record did not contain evidence treatments were completed or refused. ADON #200 confirmed the resident frequently refuses treatments and stated the care plan did not clearly identify wound care refusals as a behavioral concern. She stated staff should attempt reapproach and document all attempts.Interview on 07/08/26 at 3:55 P.M. with Licensed Practical Nurse (LPN) #156 confirmed the resident's medical record lacked documentation of treatments being completed or refused. LPN #156 stated staff must document refusals on the TAR after the second attempt and in progress notes. She confirmed the care plan did not identify wound care refusals, and refusals had become more frequent.Interview on 07/09/26 at 11:16 P.M. with MDS Coordinator #169 revealed the care plan identified resistive behaviors but did not address refusals of wound care treatments or interventions to address rejection of care. She confirmed nursing reported the resident consistently refuses dressing changes.Review of the wound care policy dated 04/28/25 revealed staff must document completion of treatments and document refusals, including the reasons for refusal, in the electronic medical record.

Based on observation, interview, record review, and facility policy, the facility failed to ensure staff maintained appropriate Personal Protective Equipment (PPE) for a resident on precautions. This affected one resident (Resident #06) of 22 residents in the survey sample. Findings include:Review of the medical record for Resident #06 revealed an admission date of 05/22/23 with diagnoses of, but not limited to, vascular dementia, type two diabetes, and peripheral vascular disease.Review of Resident #06's care plan dated 02/11/26 and revised on 05/18/26 revealed the resident was on contact precautions related to an open wound to her left stump that required a dressing and the stump was colonized with carbapenem resistant Acinetobacter baumanii and she had Methicillin-resistant Staphylococcus aureus in the wound. Interventions included to implement contact precautions and to utilize a gown and gloves when providing high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, device care/use/maintenance and wound care requiring dressings. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 08, identifying the resident as having a moderate cognitive impairment.Review of the physician orders for Resident #06 revealed an order for contact precautions every shift dated 10/15/25, and an order for an access port on the right side of chest dated 03/18/26, and an order for contact precautions for wound management dated 07/05/26.Observation on 07/06/26 at 10:30 A.M. revealed an unknown aide entering the room for Resident #06 without PPE. An additional unknown aide was also already in Resident #06's room with gloves on but was not wearing a gown. One of the aide staff was observed with gloves on, exiting Resident #06's room to get a Hoyer lift from outside of the residents' room. They re-entered the room with a Hoyer lift, with the same gloves on and no gown.Interview on 07/06/26 at 10:37 A.M. with Licensed Practical Nurse (LPN) #207 confirmed the two staff in Resident #06's room were supposed to have gloves and gowns on while assisting Resident #06. LPN #207 confirmed neither staff present in Resident #06's room had the proper PPE on and she also confirmed the staff left the residents room with gloves on, and re-entered the room with the Hoyer lift and the same contaminated gloves on and no gown.Review of the facility untitled policy related to infection control, dated 08/2022, under the area of contact precautions, revealed contact precautions are intended to prevent the transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering {i.e., before making contact with the resident or resident's environment) the room or cubicle. It also stated prior to leaving the resident's room or cubicle, the PPE is removed and hand hygiene is performed.

Based on record review, interview, and policy review, the facility failed to ensure care plans were updated and accurate for residents. This affected three residents (#11, #16, and #97) out of 22 residents in the survey sample. The resident census was 99.Findings include: 1. Review of the record for Resident #11 revealed an admission date of 03/31/26 with diagnoses of, but not limited to, dementia, Post Traumatic Stress Disorder (PTSD), alcohol dependence in remission, and aphasia. Review of the admission Minimum Data Set 3.0 dated 04/09/26 for Resident #11 revealed a Brief Interview of Mental Status score of 09, indicating a moderate cognitive impairment. a. Review of the progress notes for Resident #11 revealed on 04/30/26 and 06/01/26 the resident was found to have medications in her room. Following facility staff identifying medications in her room on 06/01/26 the physician ordered for medications to be crushed. Review of the physician notes on 04/27/26 and 05/01/26 revealed Resident #11 had a history of suicide attempts using medications. Additionally, on 04/15/26 the physician noted that at a previous facility the resident was noted to hoard her medications. The physician note on 05/01/26 also stated that staff needed to ensure the resident swallowed medications during administration and to complete intermittent room sweeps. Review of the care plan for Resident #11, initiated on 03/31/26, revealed no interventions for the resident hoarding medications, history of suicide attempts using medications, or the staff needing to ensure the resident swallowed medications during administration. Interview with the Director of Nursing on 07/09/26 at 9:30 A.M. confirmed Resident #11's care plan did not include interventions or history of the resident hoarding medications, suicide attempts utilizing medications, nor the facility's need to ensure the resident fully swallowed medications. b. Review of the Care Plan for Resident #11 initiated 03/31/26 revealed the resident had a behavior problem related to non-compliance, dementia, PTSD, sleep disorder, and depression. The care plan did not reflect triggers for the resident. Interview with the Director of Nursing (DON) on 07/09/26 revealed Resident #11 had triggers surrounding her children and how they do not visit her. The DON reported this was a topic staff should avoid. The DON further confirmed this information was not reflected in the residents' care plan. 2. Review of the medical record for Resident #97 revealed a re-admission date of 01/27/18 with diagnoses of, but not limited to, vascular dementia, muscle wasting and atrophy, osteoporosis, and anxiety disorder. Review of the Annual Minimum Data Set (MDS) 3.0 dated 04/01/26 revealed Resident #97 had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the cognitive assessment. Review of the record for Resident #97 revealed on 02/08/26 and 03/01/26 Resident #97 was involved in incidents which involved sexual conduct with another resident. The incident on 03/01/26 was related to Self-Reported Incident #271571, where Resident #97 was found to be in a male resident's room half naked with his penis in her mouth. Review of the care plan, dated 06/30/25, revealed a focus for behaviors that identified the resident would wander into other resident's rooms and may grab at others bottoms, however the care plan did not reflect the history of the residents' sexualized behaviors towards other residents. Interview with the Director of Nursing on 07/09/26 at 9:30 A.M. confirmed Resident #97 did not have her sexual behaviors care planned. 3. Review of a resident medical record revealed that Resident #16 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia, psychotic disorder with delusions and traumatic subdural hematoma. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #16 did not have Post Traumatic Stress Disorder (PTSD). Review of Resident #16's psychosocial assessment dated [DATE] revealed that Resident #16 did not have PTSD. Review of Resident #16's care plan dated 05/27/26 revealed that Resident #16 had a history of PTSD related to being a veteran of war. A listed intervention was to identify Resident #16's triggers for trauma. An interview with MDS Coordinator #169 on 07/09/26 at 2:40 P.M. revealed that she was unaware of an official PTSD diagnosis for Resident #16. MDS Coordinator #169 stated that it was an educated guess that he had PTSD since Resident #16 was known to be a veteran of war. An interview with the Director of Nursing (DON) on 07/09/26 at 2:50 P.M. confirmed that Resident #16 did not have a PTSD diagnosis and had no known triggers for his physical behaviors. The DON confirmed that the care plan indicating that Resident #16 had PTSD was incorrect. Review of the policy titled Care Planning, revised on 04/28/25, revealed care plans are to be based on the residents' comprehensive assessments and developed by a team, ensuring the development of a care plan is individualized for each resident.

Based on review of resident medical records, review of the code status book, interviews, and review of facility policy, the facility failed to clearly identify code statuses. This affected two residents (#05 and #77) out of three residents reviewed for advanced directives. The facility census was 99 residents. Findings include: 1. Review of a resident medical record revealed that Resident #05 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease, dementia, and neurocognitive Lewy body disease. Review of Resident #05's medical record revealed that a document dated 09/25/25 in Resident #05's documents indicated that Resident #05 was a full code status, indicating that life-saving measures should be administered in the event of no vital signs. The documents section did not include a signed DNR-CC document. Review of Resident #05's physician orders dated 05/11/26 revealed that Resident #05's code status was Do Not Resuscitate- Comfort Care (DNR-CC), which mandates that no life-saving measures be administered in the event of no vital signs. Review of the code status book revealed that Resident #05 was identified as being full code status. An interview with Registered Nurse (RN) #282 on 07/08/26 at 8:56 A.M. revealed that she would look at the Medication Administration Record (MAR) to determine code status for a resident. RN #282 indicated that the MAR pulls the code status from the physician's orders. An interview with Licensed Practical Nurse (LPN) #207 on 07/08/26 at 8:59 A.M. revealed that LPN #207 would check the code status book if she needed to confirm a code status. An interview with the Assistant Director of Nursing (ADON) #200 on 07/08/26 at 10:30 A.M. revealed that she would go to the code status book or the documents section of the resident's medical record to confirm code status.An interview with ADON #200 on 07/08/26 at 10:35 A.M. confirmed that Resident #05's code status orders were DNR-CC and that the code status book indicated that Resident #05 was a full code. ADON #200 confirmed that the code statuses were conflicting and had the potential to confuse nurses. 2. Review of a resident medical record revealed that Resident #77 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease, dementia and type two diabetes mellitus. Review of Resident #77's physician orders dated 06/10/25 revealed that Resident #77's code status was DNRCC, which mandates that no life-saving measures be administered in the event of no vital signs.Review of Resident #77's medical record revealed in the documents section that both a DNRCC and Do Not Resuscitate- Comfort Care Arrest (DNRCC-A (which mandates that the resident would receive full, aggressive medical treatments and life-saving interventions until a cardiac or respiratory arrest occurs) code status document was uploaded. The DNRCC-A code status signed by a physician was near the top of the documents and easily found. The DNRCC code status document was near the end of the page of the uploaded documents. Review of the code status book revealed that Resident #77 was identified as being a DNRCC-A. An interview with RN #282 on 07/08/26 at 8:56 A.M. revealed that she would look at the Medication Administration Record (MAR) to determine code status for a resident. RN #282 indicated that the MAR pulls the code status from the physician's orders. An interview with Licensed Practical Nurse (LPN) #207 on 07/08/26 at 8:59 A.M. revealed that LPN #207 would check the code status book if she needed to determine code status. An interview with the Assistant Director of Nursing (ADON) #200 on 07/08/26 at 10:30 A.M. revealed that she would go to the code status book or the documents section of the resident's medical record to confirm code status. An interview with ADON #200 on 07/08/26 at 10:35 A.M. confirmed that Resident #77's code status orders were DNR-CC and that the code status book indicated that Resident #77 was a DNRCC-A code status. ADON #200 confirmed that the code statuses were conflicting and had the potential to confuse nurses. ADON #200 confirmed that the DNRCC code status document was at the end of the uploaded documents and that the DNRCC-A code status document was easily found at the beginning of the uploaded documents. Review of the facility policy dated August 2021 and revised 04/28/25 titled, Advanced Directive Policy and Procedure, revealed that all advanced directive document copies will be obtained and maintained in the resident's medical record. Changes to the resident choices for advanced directives will be documented and all items will be communicated to staff providing resident care.

Based on record review, review of the facility Self-Reported Incidents (SRI), review of the facility investigation, review of facility policy and procedure, resident interview, and staff interview, the facility failed to ensure Resident #100 was free from resident to resident physical abuse. Actual harm occurred on 02/03/25 when Resident #57, who had a history of resident altercations and impaired cognition, pushed Resident #100 causing a fall and a right femur fracture. This affected one (Resident #100) of six residents reviewed for abuse. The facility census was 98. Findings include: a. Review of a facility submitted SRI dated 02/03/25 for physical abuse revealed Resident #57 pushed Resident #100 to the ground when Resident #100 wandered into Resident #57's room. Both residents were assessed for injuries. Resident #100 was left immobilized on the floor due to an obvious range of motion deficit to the right hip. Nine-one-one (911) was called for Resident #100's pain and range of motion deficit. Neurological checks were initiated but did not continue due to the transfer to the hospital. The medical provider and families were notified of the incident. Resident #57 was assessed for physical injuries with none noted. Resident #57 was placed on 15-minute checks until he retired for sleep at 11:00 P.M. the same day. The facility unsubstantiated abuse and marked that the evidence indicated abuse, neglect, or misappropriation did not occur. Review of the medical record for Resident #100 revealed an admitted [DATE]. Resident #100's diagnoses included Alzheimer's disease with late onset, vascular dementia, osteoarthritis, and major depressive disorder. The resident was discharged to the hospital on 02/03/25 and did not return to the facility. Review of the physician's order initiated 04/28/24 for Resident #100, revealed the resident had orders for Zoloft and Trazodone, and an order to monitor for side effects for antidepressants and report to physician: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle, tremor, agitation, headache, skin rash, photo sensitivity, and excess weight gain every shift. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 had severe cognitive impairment. Resident #100 was independent for all mobility such as transferring and walking 150 feet. Review of the care plan dated 12/20/24 revealed Resident #100 had the potential for mobility limitations with expected fluctuations with chronic medical conditions. Interventions included providing hands on assistance to steady him daily, as needed, when exhibiting weakness or resistance and to monitor his safety with the use of his assistive device. The care plan also identified Resident #100 had a tendency to misperceive information. Interventions included for the chair that he typically sits in, in the common area, to be labeled to reflect that the chair belonged to him and staff would also redirect him away from the [NAME] Pod if observed ambulating in that area, as this is where Resident #57's room was located. Review of a nursing progress note dated 02/03/25 at 11:21 P.M. revealed that Resident #100 stated that another resident [Resident #57] pushed him, and he had a fall. The note also revealed that Resident #100 was in a lot of pain and he received as needed Norco 5-325 milligrams (mg) for pain. The resident was taken to the hospital for further evaluation. Review of a nursing progress note dated 02/03/25 at 3:55 P.M. revealed Resident #100 received a fall risk assessment. The assessment indicated the resident had an unwitnessed fall that occurred in the common area and the resident was injured. The assessment note revealed another resident pushed Resident #100 and he fell . The assessment note also revealed Resident #100 had verbal complaints and facial expressions of pain. The pain was sharp and aching in the right hip and was worse with movement. Daily as needed pain medication, Norco, was administered. Review of the Incident Report dated 02/03/25 for Resident #100, revealed Resident #100 was found lying on his back on the [NAME] Pod near Resident #57's room. Resident #100 stated that a man pushed him, and he fell . Resident #100 was in a lot of pain and was given as needed Norco 5-325 mg for pain. The incident was unwitnessed. Resident #100's vital signs were taken, he was given as needed medication for pain, and neurologic checks were initiated. Resident #100 was immobilized due to an obvious range of motion deficit to his right hip. There were no obvious outward signs of skin impairment. The resident was taken to the hospital and the injury observed at the time of the incident was determined to be a fracture of the right hip. The report also stated Resident #100 was ambulating without assistance and was very territorial about particular chairs on the unit and he sought out the whereabouts of the male resident he was accusing of pushing him down, to tell him not to take his chair. Review of the Neurological Evaluation Flowsheet dated 02/03/25 for Resident #100 revealed neurologic (neuro) checks were completed at 3:30 P.M. and 3:45 P.M. Resident #100 was in the hospital for any further neuro checks. Review of the Fall Risk Evaluation dated 02/03/25 at 3:55 P.M. for Resident #100 revealed he had one to two falls in the past three months, had intermittent confusion, was ambulatory, had adequate vision, and did not have a change in condition in the last 14 days. Review of the Post Fall Evaluation dated 02/03/25 at 3:56 P.M. for Resident #100 revealed an unwitnessed fall with an injury occurred and the resident was sent to the hospital. The Certified Nurse Practitioner (CNP) #250 was notified on 02/03/25 that there was a resident to resident fall where another resident pushed Resident #100 and he fell . The evaluation noted that Resident #100 had severe right hip pain. Review of the Hospital Transfer Form dated 02/03/25 revealed Resident #100 ambulated independently, and he was alert and disoriented, but could follow simple instructions. Review of hospital records for Resident #100 revealed he had an X-ray on 02/03/25 that showed an acute obliquely oriented intertrochanteric fracture of the proximal right femur. Resident #100 received surgery on 02/04/25 for his right intertrochanteric hip fracture with osteopenia. b. Review of the medical record for Resident #57 revealed an admitted [DATE]. Resident #57's diagnoses included dementia, depression, cognitive communication deficit, and conversion disorder with seizures or convulsions. Review of the care plan for Resident #57 dated 01/22/25 revealed he was resistive to care related to dementia, he wandered about the facility, and he had the potential to become agitated if his routine or patterns of behavior were disrupted. The plan noted that Resident #57 liked to rearrange furniture in the common area, he had a history of aggression toward male residents that wandered into his room, and he was rigid with his room. Interventions included psychiatric services to evaluate and treat, provide consistency in care to promote comfort with activities of daily living (ADLs), and to maintain consistency in timing of ADLs, caregivers and routine as much as possible. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #57 revealed he had severe cognitive impairment. Resident #57 was independent for all mobility such as transferring and walking 150 feet. Review of the nursing progress note dated 02/03/25 at 12:00 A.M. for Resident #57 detailed his History and Physical which revealed Resident #57 transferred from another skilled nursing facility on 01/22/25. The note also revealed there were no previous facility records to review. Review of the nursing progress note dated 02/03/25 at 3:30 P.M. for Resident #57 revealed the resident stated he made contact with another resident. Resident #57 was assessed with no injury noted and his skin was intact. The Director of Nursing (DON), CNP #250, and the residents family member were notified. Fifteen-minute checks were initiated. Review of the incident report dated 02/03/25 at 3:30 P.M. for Resident #57 revealed Resident #57 stated I pushed that man who wandered in my room, out of the room, because I don't want anyone in my room. An assessment of Resident #57 was completed with his skin intact and no injury noted. Resident #57 received 15-minute checks through 11:00 P.M. to ensure he made no further reactive movements toward other residents. Predisposing physiological factors included Resident #57 was confused and had impaired memory. Predisposing situation factors included Resident #57 was a wanderer and he was ambulating without assistance. Resident #57 had a pattern of coming out of his room to straighten chairs and rearrange some of the chairs in the common area. Interventions included 15-minute checks through 11:00 P.M. on 02/03/25 and the activities director was to assist the resident to find activities to distract him from his patterned behavior of moving chairs around in the common area. Review of the 15-minute check log sheet dated 02/03/25 for Resident #57 revealed sign offs every 15 -minutes from 3:30 P.M. to 11:00 P.M. were completed. Review of the written staff statement dated 02/03/25 by Licensed Practical Nurse (LPN) #111 revealed she did not witness the incident, but walked into her shift and noticed Resident #100 was lying on the floor and in pain. LPN #111 gave the resident as needed pain medicine. Review of the written staff statement dated 02/03/25 by Certified Nursing Aide (CNA) #112 revealed she heard a noise and saw Resident #100 laying down and observed Resident #57 standing in front of his room looking angry. Review of the written staff statement dated 02/03/25 by Registered Nurse (RN) #14 revealed she was sitting at the nurses station and heard a scream from the common area. She saw Resident #100 on the floor on his left side. RN #14 and staff assessed Resident #100. They tried getting Resident #100 off the floor, but he was in too much pain to move around. RN #14 called 911. Review of the written interview statement dated 02/03/25 by Resident #57 revealed Resident #57 initially denied knowledge of any interaction with Resident #100. Resident #57 then stated he pushed Resident #100 out of his room because he walked in. Resident #57 stated he didn't want strangers in his room. Review of the nursing progress note dated 02/04/25 at 1:52 P.M. for Resident #57 revealed he had an altercation with another male resident who he indicated, wandered into his room. Resident #57 had some rigid behaviors involving repositioning chairs. The note indicated that activities staff would be working with him to find one on one activities to distract him. Resident #57 stated, I feel sorry the guy got a fracture. Review of physician's orders dated 02/11/25 for Resident #57 revealed the resident was to be seen by psychiatric services to evaluate and treat. An interview on 02/21/25 at 11:37 A.M. with Resident #57 revealed he had not been a part of or witnessed resident abuse. Resident #57 also revealed he had not been involved in a resident to resident altercation. An interview on 02/21/25 at 12:08 P.M. with LPN #6 confirmed Resident #100 fractured his hip during a resident to resident altercation. An interview on 02/21/25 at 12:25 P.M. with RN #23 revealed he was not at the facility for the altercation, but if two residents had an altercation it would be considered resident to resident abuse. An interview on 02/21/25 at 6:17 P.M. with the DON revealed Resident #57 had ridged behaviors of moving chairs around and Resident #100 had a chair that he [Resident #100] liked. Resident #57 moved the chair and Resident #100 went into Resident #57's room and Resident #57 pushed Resident #100 resulting in a fall. The DON stated she thought Resident #100 intimidated Resident #57, but that no one knew why Resident #100 went into #57's room. The DON confirmed that Resident #100 was injured from the shove, with a right hip fracture. The DON stated it wasn't resident to resident abuse, because the residents didn't know what they were doing based on their BIMS scores. The DON revealed they were both reacting on impulse, she didn't think they were plotting to hurt each other. An interview on 02/21/25 at 6:31 P.M. with the Administrator revealed Resident #100 liked to have his table and chair a certain way and Resident #57 liked to move chairs around the tables. Resident #100 entered Resident #57's room and Resident #57 didn't want Resident #100 in his room, so he pushed him. Resident #100 fell and was sent out [to the hospital] subsequently. The Administrator revealed she received an update after Resident #100 was sent out and he was going to have surgery. The Administrator confirmed Resident #100 had a right hip fracture when he was injured from the shove and fall. The Administrator did not claim the situation was abuse, because it was a resident to resident altercation with no intention to cause harm. The Administrator revealed the nature of the facility was dementia and they did not have an intent to harm. An interview on 02/24/25 at 12:11 P.M. with the Administrator revealed residents did not have intent and they were reacting. The Administrator also revealed nobody could be held liable for abuse of somebody else at the facility and law enforcement had told her this in the past. The Administrator explained that the residents had to have a dementia status to be at the facility and she couldn't think of a time she had ever substantiated two residents abusing each other. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2023, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The facility policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. If another resident was accused or suspected of abuse, the policy also stated the facility would ensure other residents were protected as determined by the circumstances, which may include but were not limited to, increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated. This deficiency represents non-compliance investigated under Master Complaint Number OH00162994 and Complaint Number OH00162478.

Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), hospital record review, interviews with staff, review of incident reports, and facility policy review, the facility failed to ensure care was delivered, as assessed and care planned for, utilizing the appropriate number of staff assistance during the provision of care for Resident #10. This resulted in actual harm when Resident #10 was provided care by one facility Certified Nursing Assistant (CNA) #100, who repositioned and provided incontinence care on 03/27/25 at approximately 10:00 A.M. and when Resident #10 was provided a bed bath and hair care on 03/27/25 at approximately 2:45 P.M. by one Hospice Aide #115 resulting in a comminuted femur fracture, a fracture where the bone breaks into three of more pieces often the result of major impact injury. Resident #10 was noted to have bruising to the right leg by the hospice aide (#115) on 03/27/25 when the aide was providing care alone to the resident. Resident #10 had bruising and deformity of the leg noted and was sent to the hospital for further evaluation and diagnosed with a comminuted femur fracture that required surgical intervention. This affected one (#10) of three residents (#10, #18, and #34) reviewed for injury of unknown origin. Findings Include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included dementia, atherosclerotic heart disease, Type II Diabetes Mellitus and anxiety. She was receiving hospice services. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 99 and required extensive assistance of two staff members for activities of daily living (ADL). Review of Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care for benefit period 01/17/25 to 03/27/25 revealed terminal diagnosis of frontotemporal neurocognitive disorder. Resident #10 can become very emotional, can be combative and aggressive verbally and physically. She refuses medications and personal care. She is prone to visual and auditory hallucinations. Review of the Resident #10's plan of care, dated 02/06/25, revealed she has an ADL Self-Care Performance Deficit and requires total dependence of two persons for peri care, bathing, bed mobility, personal hygiene, dressing, eating and transferring. Given Resident #10's needs and behaviors, care is to be given by two people (prefers hospice as the second caregiver). The need for two staff to provide care to Resident #10 was verified in an interview with the Director of Nursing (DON) on 04/09/25 at 10:30 A.M. Review of Resident #10's weekly wound assessments completed on 03/16/25, 03/19/25, 03/20/25, 03/23/25 and 03/26/25 revealed no concerns. Review of a Hospice Visit Note dated 03/25/25 revealed Hospice Registered Nurse (RN) #125 visited during lunch and helped her aid give her a bath, and she had no skin concerns. Review of the Weekly Skin Assessment completed on 03/27/25, after the bruising was identified by the hospice staff, revealed right knee (front) bruising light green in color, length 8.0 centimeters (cm), by 2.0 cm, no depth or stage. Review of Resident #10's nurses' progress notes from 03/25/25 to 04/09/25 revealed that on 03/27/25 Hospice Licensed Practical Nurse (LPN) #114 told facility LPN #105 that Hospice Aide #115 had notified her about a bruise on Resident #10's right knee area. Hospice LPN #114 and LPN #105 assessed Resident #10 and noted the bruise to right knee. The bruise was not previously noticed by LPN #105 on 03/24/25 when she assessed Resident #10's skin. Hospice LPN #114 notified family members and LPN #105 notified Certified Nurse Practitioner (CNP) #120. Review of the incident report dated 03/27/25, revealed Hospice Nurse/LPN #114 notified nurse that her Hospice Aide #115 noted resident with bruise near knee area. Facility Nurse LPN #105 went to assess the resident, and she had discoloration and swelling to her right knee area, also noted obvious V shaped deformity to her right femur shaft. This resident is often combative with care, but was not combative with the facility CNA #100 that did her peri care on 3/27/25 at 10:00 A.M. LPN #105 did not see bruising on knee the morning prior to Hospice Aide 115's visit. Resident #10 was interviewed and asked how the injury occurred. She kept repeating the name of Hospice Aide #115 that worked with her that day. She stated over and over She washed my hair. I did not want my hair washed. Review of the facility SRI dated 03/27/25 revealed statements were obtained from LPNs #105, #115, CNA #100 and CNA #115. Statement from facility CNA #100 revealed she changed Resident #10 in the morning and did not help the hospice aide in the afternoon with her care. Hospice Aide #115 confirmed she washed Resident #10's hair and was giving her a bed bath alone. She washed Resident #10's front of body then when she rolled the resident to her back side she saw yellow bruising on her right leg. She immediately reported it to Hospice LPN #114. Statement written by Hospice LPN #114 revealed Hospice Aide #115 reported Resident #10 had bruising, and she immediately assessed Resident #10's right leg at bedside. There was a yellow swollen area above the front right knee, and the yellow wrapped around to the back of the knee. Resident #10 requested for her to stop touching the area. She immediately reported her findings to LPN #105. Together LPN #114 and LPN #105 assessed Resident #10 and confirmed there was bruising. Review of the Hospice Visit Note dated 03/27/25 at 10:30 A.M. revealed LPN #128 was able to get Resident #10's vital signs, listen to her abdomen, and lungs and noted no concerns with visit. Review of the Hospice Client Coordination Note Report dated 03/27/25 revealed CNA #115 notified this nurse that Resident #10 had a large yellow area with swelling on leg. This nurse went to Resident #10's room. This nurse noted Resident #10 had yellow discoloration wrapping around right knee. Resident #10 had purple areas of discoloration at the back of knee. No pain noted, no warmth noted. This nurse informed facility LPN #105. This nurse and facility LPN #105 went to Resident #10's room and more area was exposed. This nurse and facility nurse noted swelling, deformity to lateral thigh and discoloration. Physician notified of findings, new order for two view x-rays of right thigh and knee. Attempted to contact Power of Attorney (POA). No answer, a message was left. The DON was notified of findings and orders. POA returned the call. POA indecisive if Resident #10 should be sent to emergency room (ER). After more conversation with the facility nurse, DON and this nurse, the POA decided to have Resident #10 sent to ER. This nurse worked in collaboration with facility nurse and the DON to transfer the resident to the hospital. Per review of Resident #10's nurses' progress notes dated 03/27/25, the medical provider for Hospice ordered a portable x-ray at the facility of the right knee/femur. Per family request Resident #10 was sent to the local emergency room for further evaluation of the right lower extremity rather than wait for the portable x-ray. At the emergency room Resident #10 was diagnosed with a right femur fracture and admitted . Surgery was performed on 03/28/25. Per review of Resident #10's Hospital Emergency Department Report dated 03/27/25 at 5:15 P.M., there is extensive subcutaneous edema throughout the right lower extremity. Clinical impression Femur Fracture. Review of the Radiographic CT Angiogram (03/27/25) of Resident #10 revealed Comminuted right distal femur fracture with 2 large fragments laterally and anterior to the distal fracture fragment. There are several additional smaller fragments. There is extensive subcutaneous edema throughout the right lower extremity. Review of the Operative Report dated 03/28/25 at 12:48 P.M. by the orthopedic surgeon revealed pre-operative diagnosis was closed right highly comminuted femoral shaft fracture. Procedure performed Retrograde Intramedullary nailing fixation of the right femur. Post-Review Operative Diagnoses Closed displaced comminuted fracture of shaft of right femur. Review of the Brief Post Operative Note by the orthopedic surgeon on 03/28/25 at 1:54 P.M. revealed operative findings: highly comminuted distal femoral shaft fracture. Severe osteopenia. Very limited hip and knee range of motion, unable to be externally rotated to access lateral hips. Review of the Trauma Service Progress Note dated 03/30/25 at 1:52 P.M. revealed injuries/active problems Right femur fracture non weight bearing (NWB) Right lower extremity (RLE) ice, pain management, frequent neurovascular checks, pathological fracture of right femur due to a combination of osteopenia and possible trauma that alone would not have caused the fracture. An interview on 04/07/25 at 10:30 A.M. with the DON confirmed facility CNA #100 performed per-care for Resident #10 alone and Hospice Aide #115 also performed ADL care alone on Resident #10 on 03/27/25. Interview on 04/07/25 at 11:55 A.M. with LPN #102 confirmed she was with LPN #105 to assess the bruising on Resident #10's right leg when it was reported by the hospice nurse. She confirmed Resident #10 was a two-person assist with ADLs. Interview on 04/07/25 at 12:03 P.M. and on 04/09/25 with facility CNA #100 confirmed Resident #10 is a two-person assist for ADLs. Because the resident was not combative on 03/27/25 she stated she provided Resident #10's peri-care in the A.M. by herself without help from another staff. She explained that on 03/27/25, she went into the room and explained to Resident #10 what she was going to do. Because she was not combative, she continued providing care alone. Resident #10 had a white bed pillow under her right knee. She moved the resident to the left, changed the under pads on the bed, then she moved her on to the right side and continued. She rolled the resident to lay on her back and applied a brief. She elevated the head of the bed and covered her and gave her a glass of water. She confirmed later in the day that the hospice aide asked her to assist with care for Resident #10's ADLs, and she stated she was unavailable to assist the hospice aide until she finished giving care to other residents on her assignment. Interviews on 04/10/25 from 7:25 A.M. to 7:40 A.M. with RN #108, CNAs #103 and #106 confirmed Resident #10 was a two-person assist before she had her knee surgery. Interview on 04/11/25 at 10:45 A.M. with Registered Nurse #300, the nurse of the Medical Physician of Orthopedic Surgery #200 clarified Resident #10's condition of osteopenia would be a contributing factor coupled with a trauma sustained by Resident #10 that resulted in a comminuted fracture requiring Resident #10 to have a retrograde intramedullary nailing fixation of the right femur procedure completed on 03/28/25. Hospice Aide #115 was unable to be reached for an interview during the survey. Review of the Facility's Incident Report from 02/07/25 to 04/07/25 revealed Resident #10 had a bruise on her finger on 03/04/25 at 07:28 A.M. and listed the new bruise discovered on 03/27/25. Review of the facility policy titled Activities of Daily Living (ADLs) Supporting, dated 08/2022 revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance.

Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), hospital record review, interviews with staff, review of incident reports, and facility policy review, the facility failed to ensure care was delivered, as assessed and care planned for, utilizing the appropriate number of staff assistance during the provision of care for Resident #10. This resulted in actual harm when Resident #10 was provided care by one facility Certified Nursing Assistant (CNA) #100, who repositioned and provided incontinence care on 03/27/25 at approximately 10:00 A.M. and when Resident #10 was provided a bed bath and hair care on 03/27/25 at approximately 2:45 P.M. by one Hospice Aide #115 resulting in a comminuted femur fracture, a fracture where the bone breaks into three of more pieces often the result of major impact injury. Resident #10 was noted to have bruising to the right leg by the hospice aide (#115) on 03/27/25 when the aide was providing care alone to the resident. Resident #10 had bruising and deformity of the leg noted and was sent to the hospital for further evaluation and diagnosed with a comminuted femur fracture that required surgical intervention. This affected one (#10) of three residents (#10, #18, and #34) reviewed for injury of unknown origin. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 01/24/25. Diagnoses included dementia, atherosclerotic heart disease, Type II Diabetes Mellitus and anxiety. She was receiving hospice services. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 99 and required extensive assistance of two staff members for activities of daily living (ADL). Review of Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care for benefit period 01/17/25 to 03/27/25 revealed terminal diagnosis of frontotemporal neurocognitive disorder. Resident #10 can become very emotional, can be combative and aggressive verbally and physically. She refuses medications and personal care. She is prone to visual and auditory hallucinations. Review of the Resident #10's plan of care, dated 02/06/25, revealed she has an ADL Self-Care Performance Deficit and requires total dependence of two persons for peri care, bathing, bed mobility, personal hygiene, dressing, eating and transferring. Given Resident #10's needs and behaviors, care is to be given by two people (prefers hospice as the second caregiver). The need for two staff to provide care to Resident #10 was verified in an interview with the Director of Nursing (DON) on 04/09/25 at 10:30 A.M. Review of Resident #10's weekly wound assessments completed on 03/16/25, 03/19/25, 03/20/25, 03/23/25 and 03/26/25 revealed no concerns. Review of a Hospice Visit Note dated 03/25/25 revealed Hospice Registered Nurse (RN) #125 visited during lunch and helped her aid give her a bath, and she had no skin concerns. Review of the Weekly Skin Assessment completed on 03/27/25, after the bruising was identified by the hospice staff, revealed right knee (front) bruising light green in color, length 8.0 centimeters (cm), by 2.0 cm, no depth or stage. Review of Resident #10's nurses' progress notes from 03/25/25 to 04/09/25 revealed that on 03/27/25 Hospice Licensed Practical Nurse (LPN) #114 told facility LPN #105 that Hospice Aide #115 had notified her about a bruise on Resident #10's right knee area. Hospice LPN #114 and LPN #105 assessed Resident #10 and noted the bruise to right knee. The bruise was not previously noticed by LPN #105 on 03/24/25 when she assessed Resident #10's skin. Hospice LPN #114 notified family members and LPN #105 notified Certified Nurse Practitioner (CNP) #120. Review of the incident report dated 03/27/25, revealed Hospice Nurse/LPN #114 notified nurse that her Hospice Aide #115 noted resident with bruise near knee area. Facility Nurse LPN #105 went to assess the resident, and she had discoloration and swelling to her right knee area, also noted obvious V shaped deformity to her right femur shaft. This resident is often combative with care, but was not combative with the facility CNA #100 that did her peri care on 3/27/25 at 10:00 A.M. LPN #105 did not see bruising on knee the morning prior to Hospice Aide 115's visit. Resident #10 was interviewed and asked how the injury occurred. She kept repeating the name of Hospice Aide #115 that worked with her that day. She stated over and over She washed my hair. I did not want my hair washed. Review of the facility SRI dated 03/27/25 revealed statements were obtained from LPNs #105, #115, CNA #100 and CNA #115. Statement from facility CNA #100 revealed she changed Resident #10 in the morning and did not help the hospice aide in the afternoon with her care. Hospice Aide #115 confirmed she washed Resident #10's hair and was giving her a bed bath alone. She washed Resident #10's front of body then when she rolled the resident to her back side she saw yellow bruising on her right leg. She immediately reported it to Hospice LPN #114. Statement written by Hospice LPN #114 revealed Hospice Aide #115 reported Resident #10 had bruising, and she immediately assessed Resident #10's right leg at bedside. There was a yellow swollen area above the front right knee, and the yellow wrapped around to the back of the knee. Resident #10 requested for her to stop touching the area. She immediately reported her findings to LPN #105. Together LPN #114 and LPN #105 assessed Resident #10 and confirmed there was bruising. Review of the Hospice Visit Note dated 03/27/25 at 10:30 A.M. revealed LPN #128 was able to get Resident #10's vital signs, listen to her abdomen, and lungs and noted no concerns with visit. Review of the Hospice Client Coordination Note Report dated 03/27/25 revealed CNA #115 notified this nurse that Resident #10 had a large yellow area with swelling on leg. This nurse went to Resident #10's room. This nurse noted Resident #10 had yellow discoloration wrapping around right knee. Resident #10 had purple areas of discoloration at the back of knee. No pain noted, no warmth noted. This nurse informed facility LPN #105. This nurse and facility LPN #105 went to Resident #10's room and more area was exposed. This nurse and facility nurse noted swelling, deformity to lateral thigh and discoloration. Physician notified of findings, new order for two view x-rays of right thigh and knee. Attempted to contact Power of Attorney (POA). No answer, a message was left. The DON was notified of findings and orders. POA returned the call. POA indecisive if Resident #10 should be sent to emergency room (ER). After more conversation with the facility nurse, DON and this nurse, the POA decided to have Resident #10 sent to ER. This nurse worked in collaboration with facility nurse and the DON to transfer the resident to the hospital. Per review of Resident #10's nurses' progress notes dated 03/27/25, the medical provider for Hospice ordered a portable x-ray at the facility of the right knee/femur. Per family request Resident #10 was sent to the local emergency room for further evaluation of the right lower extremity rather than wait for the portable x-ray. At the emergency room Resident #10 was diagnosed with a right femur fracture and admitted . Surgery was performed on 03/28/25. Per review of Resident #10's Hospital Emergency Department Report dated 03/27/25 at 5:15 P.M., there is extensive subcutaneous edema throughout the right lower extremity. Clinical impression Femur Fracture. Review of the Radiographic CT Angiogram (03/27/25) of Resident #10 revealed Comminuted right distal femur fracture with 2 large fragments laterally and anterior to the distal fracture fragment. There are several additional smaller fragments. There is extensive subcutaneous edema throughout the right lower extremity. Review of the Operative Report dated 03/28/25 at 12:48 P.M. by the orthopedic surgeon revealed pre-operative diagnosis was closed right highly comminuted femoral shaft fracture. Procedure performed Retrograde Intramedullary nailing fixation of the right femur. Post-Review Operative Diagnoses Closed displaced comminuted fracture of shaft of right femur. Review of the Brief Post Operative Note by the orthopedic surgeon on 03/28/25 at 1:54 P.M. revealed operative findings: highly comminuted distal femoral shaft fracture. Severe osteopenia. Very limited hip and knee range of motion, unable to be externally rotated to access lateral hips. Review of the Trauma Service Progress Note dated 03/30/25 at 1:52 P.M. revealed injuries/active problems Right femur fracture non weight bearing (NWB) Right lower extremity (RLE) ice, pain management, frequent neurovascular checks, pathological fracture of right femur due to a combination of osteopenia and possible trauma that alone would not have caused the fracture. An interview on 04/07/25 at 10:30 A.M. with the DON confirmed facility CNA #100 performed per-care for Resident #10 alone and Hospice Aide #115 also performed ADL care alone on Resident #10 on 03/27/25. Interview on 04/07/25 at 11:55 A.M. with LPN #102 confirmed she was with LPN #105 to assess the bruising on Resident #10's right leg when it was reported by the hospice nurse. She confirmed Resident #10 was a two-person assist with ADLs. Interview on 04/07/25 at 12:03 P.M. and on 04/09/25 with facility CNA #100 confirmed Resident #10 is a two-person assist for ADLs. Because the resident was not combative on 03/27/25 she stated she provided Resident #10's peri-care in the A.M. by herself without help from another staff. She explained that on 03/27/25, she went into the room and explained to Resident #10 what she was going to do. Because she was not combative, she continued providing care alone. Resident #10 had a white bed pillow under her right knee. She moved the resident to the left, changed the under pads on the bed, then she moved her on to the right side and continued. She rolled the resident to lay on her back and applied a brief. She elevated the head of the bed and covered her and gave her a glass of water. She confirmed later in the day that the hospice aide asked her to assist with care for Resident #10's ADLs, and she stated she was unavailable to assist the hospice aide until she finished giving care to other residents on her assignment. Interviews on 04/10/25 from 7:25 A.M. to 7:40 A.M. with RN #108, CNAs #103 and #106 confirmed Resident #10 was a two-person assist before she had her knee surgery. Interview on 04/11/25 at 10:45 A.M. with Registered Nurse #300, the nurse of the Medical Physician of Orthopedic Surgery #200 clarified Resident #10's condition of osteopenia would be a contributing factor coupled with a trauma sustained by Resident #10 that resulted in a comminuted fracture requiring Resident #10 to have a retrograde intramedullary nailing fixation of the right femur procedure completed on 03/28/25. Hospice Aide #115 was unable to be reached for an interview during the survey. Review of the Facility's Incident Report from 02/07/25 to 04/07/25 revealed Resident #10 had a bruise on her finger on 03/04/25 at 07:28 A.M. and listed the new bruise discovered on 03/27/25. Review of the facility policy titled Activities of Daily Living (ADLs) Supporting, dated 08/2022 revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance.

Based on staff interviews, review of self-reported incident investigations (SRI) and policy review, the facility failed to ensure allegations of abuse, neglect, misappropriation and injuries of unknown origin were thoroughly investigated and interventions put in place. This affected eight Residents (#20, #21, #33, #48, #52, #54, #89 and #100) of nine reviewed for abuse, neglect and misappropriation investigations. The facility census was 96. Findings include 1. Review of the medical record for Resident #54 revealed an admitted [DATE]. Diagnoses included multiple rib fractures, Alzheimer's disease, dementia, aphasia, diabetes, depression, osteoporosis and restlessness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 05 and required substantial assistance for showering bathing and dressing Review of SRI 252935 regarding an injury of unknown origin for Resident #54 dated 10/12/24 revealed no resident interviews or statements were completed and an intervention of 15-minute checks was to be initiated. The facility had no evidence of any 15-minute checks being completed for Resident #54. Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no evidence of 15-minute checks being completed. She acknowledged the interventions were not typical for an injury of unknown origin but confirmed it was mentioned multiple times in the investigation. 2. Review of the medical record for Resident #89 revealed an admitted [DATE]. Diagnoses included unspecified dementia, aphasia, vascular disease, diabetes, epilepsy, hemiplegia and hemiparesis, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively impaired with a BIMS of 03 and required extensive assistance for bed mobility and transfers, partial/moderate assistance for bathing and dressing, and substantial maximum assistance for personal hygiene. Review of SRI 255726 and SRI 255654 for misappropriation involving Resident #89 dated 12/31/24 and 01/03/25 revealed no resident interviews or statements were completed. The investigation did not include the questions asked of staff and was not specific to a missing wedding ring and clothes but included information about a different ring sent home with family. Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed facility investigation was a mix of information related to the previous ring that was reported missing and the new ring that Resident #89's family had provided. DON also revealed facility spoke with the abuse department at Ohio Department of Health and did not include any of those interactions in the investigation steps and when new information was found, facility provided no information indicating the abuse officer was updated. The facility also agreed they did not consider staff working prior to the allegation of the ring being missing but only considered and looked at staff working after the allegation was made on 12/24/24. DON revealed the staff would have also worked prior to the allegation. 3. Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses included dementia, catatonic disorder, aphasia, depression, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired with a BIMS of 00. Review of the medical record for Resident #100 revealed an admitted [DATE] and discharge date [DATE]. Diagnoses included dementia, muscle weakness, bipolar disorder, and pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively impaired with a BIMS of 10. Review of SRI 253374 for physical abuse of a resident-to-resident altercation between Resident #52 and Resident #100 dated 10/27/24 revealed no resident interviews or statements were completed. An intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of 15-minute checks being completed for Resident #100 showed the incident occurred at 9:00 A.M. missing entries 10/27/24 from 9:00 A.M. to 9:30 A.M., at 3:15 P.M., 3:45 P.M. to 4:15 P.M., 6:30 P.M., 7:00 P.M., 8:15 P.M., and 9:00 P.M. Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no additional evidence of 15-minute checks being completed. She acknowledged the interventions were missing multiple entries and documentation was missing several sections. DON revealed each box should be completed and confirmed staff used lines and arrows for shorthand and confirmed several sections were left with no documentation to prove 15-minute checks were completed. 4. Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included heart disease, depression, hypertension, aphasia, chronic pain, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively impaired with a BIMS of 07. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included dislocation of left humerus, Alzheimer's disease, malnutrition, aphasia, heart disease and vascular dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively impaired with a BIMS of 08. Review of SRI 254391 for physical abuse of a resident-to-resident altercation between Resident #33 and Resident #48 dated 11/22/24 revealed no resident interviews or statements were completed. An intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of 15-minute checks being completed for Resident #48 which showed the incident occurred at 10:39 P.M. and was missing all entries on 11/23/24 from 2:00 A.M. to 9:30 A.M. Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed the facility had no additional evidence of 15-minute checks being completed. She acknowledged the interventions were missing multiple entries. 5. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included vascular dementia, hemiplegia and hemiparesis, aphasia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively impaired with a BIMS of 08. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included vascular parkinsonism, insomnia, aphasia, vascular dementia and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired with a BIMS of 01. Review of SRI 254574 for physical abuse of a resident-to-resident altercation between Resident #20 and Resident #21 dated 11/28/24 revealed no resident interviews or statements were completed. An intervention of 15-minute checks was to be initiated for 24 hours. The facility provided evidence of 15-minute checks being completed for Resident #20 showed the incident occurred at 9:00 P.M. and had two separate forms dated 11/29/24 completed by two different staff and stated resident was in two different locations for the entirety of this time period 3:00 P.M. through 3:45 P.M. Interview on 01/14/25 at 4:42 P.M. with Director of Nursing revealed facility had no additional evidence of 15-minute checks being completed. She acknowledged the intervention was completed on different forms for the same time period and provided no reasoning for two different staff completing the checks and different information being provided for the same residents at the same times. Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2023 revealed facility staff shall immediately report all such allegations to the Administrator. Facility shall complete an investigation into the alleged violation within five working days. The actions to be taken include interview the resident, the accused, and all witnesses including anyone who come in contact with the resident(s) the day of the incident. If there were no direct witnesses, interviews should be expanded for example all staff on the shift in question. For injuries of unknown origin facility may generally interview staff working on the shift the injury was discovered as well as shifts prior to the incident. Facility shall review all applicable medical records and document all evidence of the investigation. At the end of the investigation, facility shall make a conclusion whether to substantiate the claim vs unsubstantiated the claim. Facility shall follow up by completing any necessary staff education and implementing any other measures deemed appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00161067.

Based on staff interview, resident interview, family interview, review of the self-reported misappropriation incident investigation and review of the abuse policy, facility failed to ensure allegations of misappropriation were reported to the state agency in a timely manner. This affected one (Resident #89) of one reviewed for misappropriation. The facility census was 96. Findings include Review of the medical record for Resident #89 revealed an admitted [DATE]. Diagnoses included unspecified dementia, aphasia, vascular disease, diabetes, epilepsy, hemiplegia and hemiparesis, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 03 and required extensive assistance for bed mobility and transfers, partial/moderate assist for bathing and dressing, and substantial maximum assistance for personal hygiene. Review of the plan of care dated 12/30/24 revealed the resident had a behavior problem and fidgets with most things including jewelry and remote. Interventions included to develop more appropriate methods for coping and interacting, monitor behaviors for delusions and paranoia. Review of the Self-reported Incident investigation (SRI) for Misappropriation dated 12/31/24 revealed Resident #89's family member had reported her wedding ring was missing. Facility staff searched for the ring, checked laundry and could not locate the ring. Staff statement from Unit Manager #67 dated 01/03/24 revealed on 12/24/24 Resident #89's sister contacted her to report the missing wedding ring. She revealed she informed family she would look for it and follow up with them on any outcome. She searched for the ring that day without success. On 12/31/24 Director of Nursing was informed by Resident's husband of the missing wedding band and an SRI was initiated. Review of disciplinary action dated 01/02/25 with meeting on 01/03/25 revealed Unit Manager #67 received a written warning related to not following the abuse policy. Facility management was not informed timely after a report of the missing wedding ring for Resident #89 and the SRI was therefore not reported in a timely manner. Interview on 01/14/25 at 10:40 A.M. with Unit Manager #67 revealed she was informed of the missing ring by residents family prior to Christmas and looked for it but did not tell anyone as the typical staff she would alert were off work. She revealed she then went on vacation and did not return until after the new year. When she returned she was informed family had brought up the ring again to the Director of Nursing and an investigation was started. Unit Manager reported she received a write up for not reporting the concern to management back on 12/24/24 when it was reported to her. Interview on 01/14/25 at 2:20 P.M. with Director of Nursing (DON) revealed Unit Manager should have reported the concern of the missing wedding ring to management on 12/24/24 when it was first reported to her. DON also confirmed this led to a delay in facility reporting the SRI to the Department of Health. Review of facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2023 revealed facility staff shall immediately report all such allegations to the Administrator and Ohio Department of Health in accordance with procedures in this policy. Facility shall ensure staff know how to identify Abuse, neglect and misappropriation of resident property. Events of misappropriation shall be reported to the Ohio Department of Heath (ODH) within 24 hours from the time the incident is known to a staff member. This deficiency represents non-compliance investigated under Complaint Number OH00161067.

Based on observations and staff interviews the facility failed to ensure call lights were in reach and accessible for resident use. This affected two residents (#35 and #54) of two observed laying in their bed in their rooms. Facility census was 96. Findings include: 1. Review of the medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included dementia, osteoarthritis, aphasia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired with a BIMS of 99 (unable to determine due to lack of responses in answering) and required extensive assistance of two staff members for bed mobility and extensive assistance of one staff member for transfers. Observation and interview on 01/14/25 at 9:35 A.M. revealed Resident #35's call light was not within reach. It was hung back behind the headboard over the clock hanging on the wall about 6 feet from the ground. Registered Nurse (RN) #53 confirmed the call light was hung up over the wall clock and was out of reach for the resident. She revealed possibly the staff feeding her hung it up then forgot to give it back. RN #53 confirmed the call light should be left in resident reach at all times, while she was in bed. 2. Review of the medical record for Resident #54 revealed an admitted [DATE]. Diagnoses included multiple rib fractures, Alzheimer's disease, dementia, aphasia, diabetes, depression, osteoporosis and restlessness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively impaired with a BIMS of 05 and required substantial assistance for showering bathing and dressing Observation and interview on 01/14/25 at 12:20 P.M. revealed Resident #54's call light was not within reach. It hung from the plug against the wall and under the bed at the foot board end of the bed. RN #53 confirmed the call light was on the floor under the foot board side of the bed and had to climb around the bed to retrieve it. RN #53 confirmed the call light should always be left in resident reach, while the resident was in bed. Interview on 01/14/25 at 2:30 P.M. with Administrator and Director of Nursing revealed they did not believe the facility had a policy related to residents having access to their call light devices but would check. No policy was provided.

Based on facility document review and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all residents residing in the facility. The facility census was 99. Findings include: Review of the facility assessment updated 08/19/24 revealed the assessment was completed using a facility assessment tool which provided guidelines and prompts for completing a comprehensive assessment. The section prompting the facility to describe ethnic, cultural, or religious factors or personal resident preferences that could affect the care provided to the residents was blank. The section prompting the facility to list contracts, memoranda of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies, such as transfer agreements, was blank. The section prompting the facility to list their health information technology resources for electronically managing patient records and electronically sharing information with other organizations, was blank. The section prompting the facility to provide the facility-based and community-based risk assessment, utilizing an all-hazards approach, was blank. There were no attachments or addendums. The assessment listed the updated facility assessment was to be reviewed at the Quality Assurance/Performance Improvement (QAPI) meeting scheduled for 08/26/24. Interview on 08/26/24 at 8:48 A.M. with the Administrator confirmed the facility assessment was updated 08/19/24. Interview on 08/26/24 at 4:10 P.M. with the Director of Nursing (DON) confirmed the facility had four residents whose primary language was not English. The DON confirmed two residents spoke French Creole, one resident spoke [NAME], and one resident spoke Vietnamese. The DON shared the facility held their scheduled QAPI meeting early in the day of 08/26/24, but none of the QAPI members in attendance had time to read the multiple pages of the facility assessment. The DON confirmed the facility assessment sections regarding ethnic, cultural, or religious factors, contracts and agreements with third parties, health information technology resources, and the facility-based and community-based risk assessments were blank.

Based on observation, staff interview, and review of the facility policy, the facility failed to prevent clean equipment and utensils from contamination, failed to maintain kitchen equipment in operating condition, and failed to follow proper datemarking procedures. This had the potential to affect all residents with the exception of Residents #26 and #90 who receive nothing by mouth. The facility census was 99 residents. Findings include: 1. Observation on 08/19/24 at 04:18 P.M. revealed there was a rectangular door on the ceiling above a storage rack for clean pots and pans with chipped paint on the door and all around the door frame. Interview on 08/19/24 at 04:18 P.M. with Dietary Director (DD) #570 confirmed the clean pots and pans were stored underneath the ceiling door to the attic access and the chipping paint could fall on the clean pots and pans. Review of the facility policy titled Cross Contamination Overview dated August 2008 revealed physical contaminants included foreign objects that might inadvertently enter the food. 2. Observation on 08/19/24 at 04:33 P.M. in the dish room with DD#570 revealed there was a pink pool of liquid near the drain. Interview on 08/19/24 04:34 P.M. with DD#570 confirmed that the garbage disposal had a leak for approximately two months prior to the survey and the leak allowed fluid to pool on the floor of the dish room. DD #570 further confirmed the facility had a new garbage disposal, but the facility staff had not installed it yet. Observation on 08/21/24 at 10:18 A.M. revealed the garbage disposal was leaking with water pooling on the floor underneath. There was red fluid dripping from the disposal. Interview on 08/21/24 at 10:18 A.M. with DD#570 confirmed the red fluid leaking from the garbage disposal was cranberry juice. Interview on 08/26/24 at 08:49 A.M. with DD #570 confirmed the kitchen staff performed general monitoring of the kitchen equipment every day. Review of the facility policy titled Floor Cleaning dated August 2008 revealed all kitchen floors should be cleaned as needed or at a minimum after each meal. Review of the work orders from the last six months revealed there were no work orders regarding the garbage disposal leaking on the floor. Review of the facility policy titled Maintenance Records dated August 2008 revealed a work order request should be completed for all equipment in need of repair. 3. Observation on 08/19/24 at 04:52 P.M. of the walk-in cooler revealed there was a bag of sliced yellow and white cheese that was dated 08/07/24 and a bag of shredded cheese dated 08/08/24. Interview on 08/19/24 at 04:54 P.M. with DD #570 confirmed the hold time for cheese was seven days and the bags of cheese should have been discarded. Observation on 08/19/24 at 04:56 P.M. with DD #570 revealed the walk-in cooler contained a large half sliced log of undated bologna. Interview on 08/19/24 at 04:56 P.M. with DD #570 confirmed there was no date on the open log of bologna, and it should be discarded. Observation on 08/21/24 at 12:54 P.M with DD #570 revealed the walk-in cooler contained a bin of mushrooms dated 08/12/24. Interview on 08/21/24 at 12:54 P.M. with DD#570 confirmed the mushrooms were out of date and should be discarded. Interview on 08/26/24 at 08:49 A.M. with DD #570 confirmed the facility datemarking policy was the date opened plus 6 days out. DD #570 further confirmed the date of disposal was to be marked on the product. Review of the facility policy titled Datemarking dated August 2008 revealed food maintained at a temperature of 41 degrees Fahrenheit (F) or less, should be marked to be used in seven calendar days. 4. Observation on 08/19/24 at 04:58 P.M. revealed the noncommercial microwave had peeling metal around the interior edge and on the inside of the microwave. Interview on 08/19/24 at 04:59 P.M. with DD#570 revealed the microwave was not commercial grade and there was peeling metal on the edge and inside the microwave. Interview on 08/20/24 at 03:00 P.M. with Maintenance Director (MD) #801 confirmed the microwave in the facility kitchen was not commercial grade. Interview on 08/21/24 at 12:48 P.M. with DD #570 confirmed the microwave was not commercial grade and had peeling metal on the edge and inside the microwave. DD #570 further confirmed the local health department told the facility to get a commercial grade microwave. Interview on 08/26/24 at 08:49 A.M. with Dietary Director #570 confirmed the kitchen staff performed general monitoring of kitchen equipment every day. Review of the facility policy titled Microwave Cleaning dated August 2008 revealed the microwave should be cleaned and sanitized as needed or at a minimum daily. Review of the work orders from the last six months revealed there were no work orders for the microwave. Review of the facility policy titled Maintenance Records dated August 2008 revealed a work order request should be completed for all equipment in need of repair. 5. Observation on 08/19/24 at 05:00 P.M. of the reach-in cooler revealed there was a large amount of water pooling in the bottom. Interview on 08/19/24 at 05:00 P.M. with DD #570 confirmed water was pooling at the bottom of the cooler. DD #570 confirmed the cooler did that every couple of weeks. Observation on 08/21/24 at 12:04 P.M. revealed water was pooling in the bottom of the reach-in cooler. Interview on 08/21/24 at 12:05 P.M. with the DD #570 confirmed water was pooling in the bottom of the unit again. Review of the policy titled Refrigerator, Reach-in Cleaning dated August 2008 revealed all refrigerators should be cleaned and sanitized as needed or at a minimum monthly. Review of the work orders from the last six months revealed there were no work orders for water pooling at the bottom of the reach in cooler.

Based on personnel file review, staff interview and review of a job description, the facility failed to ensure a qualified Activity Director (AD) was in place to oversee the facility's overall activity services. This had the potential to affect all 99 resident residing in the facility. The census was 99. Findings include: Review of personnel files on 08/21/24 at 1:20 P.M. revealed Activities Director (AD) #608 was hired as activities aid 10/30/22 part-time. Staff #608 had a high school diploma and had attended some collage studying social work but did not graduate. Staff #608 resigned her part-time position 01/19/23 and became employed on an as needed or PRN basis. A new application to be activities aid full-time was submitted on 09/26/23 and human resources documents indicate this is when Staff #608 became a full-time activities assistant. Staff #608 was promoted to Activities Manager 04/05/2024. Interview on 08/20/24 at 03:26 P.M. with AD #608 confirmed she is not certified yet. AD #608 stated she has worked here for three years as activity assistant; 5 months as director. AD #608 confirmed she not certified as an activities director but believes facility is going to pay for her education but they had not done that yet. AD #608 confirmed there are 9-10 activity staff members here at the facility; AD #608 confirmed so staff at the facility are certified to be an Activities Director. AD #608 stated there is no regional or corporate activity person/oversight. When asked how she decides what activities are needed; AD #608 stated she uses online resources and online groups for ideas in planning activities. Interview on 08/21/24 at 1:35 P.M. with Human Resources Director (HRD) #775 confirmed AD #608 was hired as activities aid 10/30/22 part-time, and resigned her part-time position 01/19/23 and became employed on an as needed or PRN basis. A new application to be activities aid full-time was submitted on 09/26/23 and human resources documents indicate this is when AD #608 became a full-time activities assistant. HRD #775 stated AD #608 was promoted to Activities Manager 04/05/2024. HRD #775 confirmed AD #608 did not meet the criteria to be an activities director as she did not have an associates degree or certification and did not have two years full-time experience as an activities aid. HRD #775 stated AD #608 had just over six months experience full-time as an activities aid. Review of the Position Description for Activities Director (created on 06/01/05) signed by AD #608 on 04/05/24 revealed the facility requirements for an Activities Director state: 1. Associates degree in recreation is required. 2. Must have two years experience in long-term care as a supervisor 3. In lieu of college degree will consider an applicant with two years experience in recreation department plus the required two years supervisory experience. 4. Certification in accordance with regulatory agencies is required. Interview on 08/27/24 at 2:20 P.M. with HRD #775 confirmed AD #608 did not have two years experience in activities; she had one year six months experience and only six months of that was full-time. AD #608 had no supervisory experience and has no degree or certification.

Based on observation, staff interview, medical record review, policy review, and review of manufacturer's guidelines, the facility failed to ensure medications were labeled and stored appropriately per manufacturer's guidelines and failed to ensure medication carts were secured when not in use. This had the potential to affect all residents residing in the facility. The facility census was 99 residents. Findings include: 1.Observation on 08/21/24 at 8:52 A.M. revealed Registered Nurse (RN) #190 was at her medication cart preparing medications on the 300 unit. RN #190 had a cup of crushed medications mixed with applesauce in her hand. RN #190 turned her back to the medication cart and walked approximately 30 feet to the center of the dining room and did not lock her medication cart. RN #190 returned to the cart approximately one minute later. Interview on 08/21/23 at 8:54 A.M. with RN #190 confirmed she had left her medication unlocked and unattended. Observation on 08/21/24 at 2:19 P.M. revealed RN #120 at her medication cart in the Pink hall of the skilled unit. RN #120 had a cup of pills in her hand, turned her back to the medication cart and walked into a resident's room without locking her medication cart. Four residents were observed in the pink hallway of the skilled unit near the nurse's station/lounge area within 15 feet of RN #120's medication cart. RN #120 returned to her medication cart at 2:23 P.M. Interview on 08/21/24 at 2:24 P.M. with RN #120 confirmed she left her cart unlocked and unattended and should not have done so. Review of the policy titled Medication Dispensing System undated revealed medication carts were always to be locked when out of sight or unattended. 2. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, glaucoma, and osteoarthritis. Review of the Minimum Date Set (MDS) assessment for Resident #8 dated 03/14/23 revealed the resident was cognitively impaired. Review of the August 2024 physician's orders for Resident #8 revealed an order for Cosopt ophthalmic solution (eye drops used to treat glaucoma) one drop in each eye twice daily. Review of the Medication Administration Record (MAR) for Resident #8 dated August 2024 revealed the resident's eye drops had been recorded as administered twice daily from 08/01/24 through 08/21/24. Observation on 08/21/24 at 9:43 A.M. revealed RN #120 administered Resident #8's Cosopt ophthalmic solution. Neither the Cosopt eye drop box nor the vial contained a date the medication was opened. The vial did list 03/09/24 as the date the medication was delivered by the pharmacy. Interview on 08/21/24 at 10:09 A.M. with RN #120 confirmed there was no date opened listed on the Cosopt eye drop vial or box. RN #120 confirmed the printed fill date from the pharmacy listed on label of the vial and box read 03/09/24. RN #120 was unsure when eye drops should be discarded after opening. Interview on 08/21/24 at 10:18 A.M. with Licensed Practical Nurse (LPN) #215 confirmed she was unsure when eye drops should be discarded after opening. Review of the facility policy titled Medications with Shortened Expiration Dates undated revealed medications in multiple dose-containers should be discarded 28 days after opening unless otherwise specified by the manufacturer. Review of the manufacturer's information for Cosopt eye drops/solution dated 12/12/16 revealed Cosopt can be used for 28 days after first opening the container and then should be discarded. 3. Observation on 08/21/24 at 2:53 P.M. with LPN #227 revealed the medication room refrigerator on the 300 unit contained a box which contained an open undated vial of tuberculin testing solution and a vial of influenza vaccine which was being stored in a tuberculin testing solution box. Interview on 08/21/24 at 2:53 P.M. with LPN #227 confirmed the tuberculin testing solution should be dated when opened and should be discarded within 30 days. LPN #227 further confirmed the influenza vial should not be stored inside a tuberculin testing solution box as a staff member could easily grab the wrong vial. Review of the manufacturer's package insert for tuberculin testing solution dated November 2013 revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which might affect potency.

Based on observation, interviews, and record review, the facility failed to maintain a clean and homelike environment for seven (#18, #26, #35, #44, #78, #90, and #92) residents, all residents were screened during the annual survey. The facility census was 99. Findings include: 1. Review of Resident #44's medical record identified admission to the facility occurred on 07/18/17 with medical diagnosis including aphasia, Alzheimer's disease, and dementia. Observation on 08/19/24 at 3:47 P.M. of Resident #44's room revealed the room was filthy, the floor was sticky causing feet to stick to the floor. The bedspread was visibly soiled and the wall behind the bed was stained with residue. Observation on 08/22/24 at 10:31 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #44's room revealed the floor was very sticky and there were brown and yellow stains on the wall next to Resident #44's bed. Interview on 08/22/24 at 10:31 A.M. with Maintenance Director #801 verified the floor was sticky. Interview on 08/22/24 at 10:31 A.M. with Housekeeping Supervisor #615 verified the stains on the wall next to the resident's bed. 2. Review of Resident #78's medical record identified admission to the facility occurred on 05/14/22 with medical diagnosis including depression, generalized anxiety disorder, and dementia. Observation on 08/19/24 11:19 at A.M. revealed Resident #78's room includes one pink wall with patches of white where it has been repaired. There was not one single picture or photo on any wall. The floor was very sticky. There was dried residue on the bathroom floor to left side of toilet and commode. Observation on 08/22/24 at 10:42 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #78's room revealed the floor was very sticky and there were little black balls all over the floor. Interview on 08/22/24 at 10:42 A.M. with Housekeeping Supervisor #615 confirmed the room floor was sticky and the bathroom floor was soiled. Interview on 08/22/24 at 10:46 A.M. with Maintenance Director #801 confirmed there were shredded rubber pellets on the room floor. Review of the undated Routine Cleaning and Disinfection Policy stated This facility's policy is to ensure routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. 3. Review of Resident #26's medical record identified admission to the facility occurred on 12/29/21 with medical diagnosis including depression, epilepsy, and dementia. Observation on 08/20/24 at 8:51 A.M. of Resident #26's room revealed the walls were scuffed there were drywall patches by the bed. Observation on 08/22/24 at 10:56 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #26's room revealed there was nothing on the walls in room and the room was not in a homelike condition. Interview on 08/22/24 at 10:57 A.M. with Housekeeping Supervisor #615, Maintenance Director #801, and Activity Supervisor #608 all confirmed there was nothing in the room. 4. Review of Resident #90's medical record identified admission to the facility occurred on 12/12/23 with medical diagnosis including traumatic hemorrhage of cerebrum, depression, and dementia. Observation on 08/19/24 at 10:10 A.M. revealed Resident #90's walls were scuffed and had dry wall patches showing throughout the room. Observation on 08/20/24 at 9:22 A.M. of Resident #90's room revealed the room was not homelike. There was nothing on the walls. Observation on 08/22/24 at 11:13 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #90's room revealed there was nothing on walls of the room and it was not in a homelike condition. Interview on 08/22/24 at 11:13 A.M. with Housekeeping Supervisor #615 confirmed there was nothing on the walls. 5. Review of Resident #35's medical record identified admission to the facility occurred on 03/01/24 with medical diagnosis including depression, aphasia, and dementia. Observation on 08/20/24 at 9:15 A.M. revealed Resident #35's wall and ceiling are patched with drywall and scuffed. Observation on 08/22/24 at 10:59 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #35's room revealed there is nothing on Resident #35's side of the room and it is not in a homelike condition. Also observed was a piece of coving missing which exposed valves and there was broken flooring in front of the room. Interview on 08/22/24 at 10:59 A.M. with Housekeeping Supervisor #615 confirmed there was nothing in Resident #35's room. Interview on 08/22/24 at 11:00 A.M. with Maintenance Director #801 confirmed there was missing coving with exposed valves and there is broken flooring in front of the room. 6. Review of Resident #92's medical record identified admission to the facility occurred on 03/14/24 with medical diagnosis including dementia, depression, and bipolar disorder. Observation on 08/20/24 at 9:00 A.M. of Resident #92's room revealed the room was not homelike. Observation on 08/22/24 at 10:33 A.M. with Maintenance Director #801 and Housekeeping Supervisor #615 of Resident #92's room revealed there was nothing in the room to look at. It was not in a homelike condition. Interview on 08/22/24 at 10:33 A.M. with Housekeeping Supervisor #615 confirmed nothing was in the room. Housekeeping Supervisor #615 said there are supposed to be clocks and dressers in the room. 7. Review of Resident #18's medical record identified admission to the facility occurred on 01/10/19 with medical diagnosis including insomnia, Alzheimer's disease, and dementia. Observation on 08/22/24 at 11:13 A.M. of Resident #18's room with Maintenance Director #801 and Housekeeping Supervisor #615 revealed there is nothing on the walls in the room and it was not in a homelike condition. Interview on 08/22/24 at 11:13 A.M. with Housekeeping Supervisor #615 confirmed there is nothing on the walls. Review of the Quality of Life-Homelike Environment policy dated May 2017 stated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on medical record review, observation, staff interview, policy review, and review of manufacturer's guidelines, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had four medication errors of 31 opportunities for an error rate of 12.9 %. This affected four (Residents #64, #27, #08, and #49) of five residents reviewed for medication administration. The facility census was 99 residents. Findings include: 1. Review of the medical record for Resident #64 revealed an admitted [DATE] with diagnoses including dementia, type two diabetes mellitus, paranoid schizophrenia, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #64 dated 07/23/24 revealed the resident had intact cognition. Review of the physician's orders for Resident #64 revealed an order dated 09/01/23 for Namenda 10 milligram (mg) one tablet by mouth twice daily. Observation on 08/21/24 at 8:38 A.M. revealed Licensed Practical Nurse (LPN) #470 prepared Resident #64's morning medications for administration. Namenda was not available for administration. Interview on 08/21/24 at 8:38 A.M. with LPN #470 confirmed Namenda for Resident #64 was not available for administration. LPN #470 confirmed she would order the medication from the pharmacy, and it should arrive later in the day. Observation on 08/21/24 at 9:30 A.M. with LPN #120 revealed the skilled hallway medication room contained the facility's emergency supply of commonly ordered and/or used medication. The supply included six Namenda 5 mg tablets. Interview on 08/21/24 at 11:10 A.M. with the Director of Nursing (DON) confirmed she was not notified that Resident #64 did not receive his morning dose of Namenda 10 mg, and LPN #470 should have retrieved Namenda from the facility's emergency supply so he did not miss his dose of medication. 2. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including dementia, depression, osteoarthritis, and hypertension. Review of the MDS assessment for Resident #27 dated 07/02/24 revealed the resident had moderately impaired cognition. Review of the physician's orders for Resident #27 revealed an order dated 08/07/24 for Zoloft 150 mg every morning. Observation on 08/21/24 at 9:18 A.M. revealed Registered Nurse (RN) #120 prepared Resident #27's morning medications. RN #120 checked the cards of medications and stated she only had Zoloft 100 mg tablets present in the medication cart and was missing a 50 mg tablet of Zoloft to make up the total dose of 150 mg. Observation on 08/21/24 at 9:30 A.M. with RN #120 revealed the emergency supply of medications included six 125 mg Zoloft tablets. Interview on 08/21/24 at 9:30 A.M. with RN #120 confirmed the doses of Zoloft in the emergency supply were 125 mg per dose and would not work to make up Resident #27's dose of Zoloft 150 mg. RN #120 confirmed she would not be able to administer Resident #27's full dose of Zoloft and would give him a partial dose of 100 mg. Observation on 08/21/24 at 9:36 A.M. revealed RN #120 administered Zoloft 100 mg to Resident #27. Interview on 08/21/24 at 9:52 A.M. with Unit Manager (UM), LPN #215 confirmed Zoloft 50 mg for Resident #27 had been ordered from the pharmacy and would not arrive till later in the afternoon. 3. Review of the medical record for Resident #08 revealed an admitted [DATE] with medical diagnoses included glaucoma, Alzheimer's disease, depression, and aphasia. Review of the MDS assessment for Resident #08 dated 03/14/23 revealed the resident was cognitively impaired. Review of the physician's orders for Resident #08 revealed an order dated 07/26/22 for Senna-S 8.6-50 mg 1 tablet by mouth twice daily. Review of the Medication Administration Record (MAR) for Resident #08 dated August 2024 revealed Senna S had been signed as given twice daily from 08/01/24 to 08/21/24's morning dose. Observation on 08/21/24 at 9:43 A.M. revealed RN #160 administered a Senna 8.6 mg tablet to Resident #08 with his morning medications. Interview on 08/21/24 at 10:09 A.M. with RN #160 confirmed she gave Resident #08 the wrong laxative. RN #160 confirmed she gave the resident a dose of senna 8.6 mg, because she did not have a bottle of Senna-S in the medication cart. RN #160 stated she could have checked the medication room or central supply as it was an over-the-counter medication, but the Senna 8.6 mg was close enough to the ordered Senna-S tablets. 4. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including type two diabetes and hemiplegia and hemiparesis following a cerebrovascular accident. Review of the MDS assessment for Resident #49 dated 06/29/24 revealed the resident was cognitively impaired and received insulin injections. Review of the physician's orders for Resident #49 revealed an order dated 02/23/24 for Humalog insulin two units by subcutaneous injection three times daily before meals. Observation on 08/21/24 at 11:55 A.M. revealed Registered Nurse (RN) #190 applied a clean needle to the Humalog insulin pen, dialed the pen to 2 units, cleansed a site on Resident #49's left upper arm, and administered the Humalog to the resident. RN #190 did not prime the needle prior to administering the resident's medication. Interview on 08/21/24 at 12:00 P.M. with RN #190 confirmed she did not prime the insulin pen for Resident #49 after applying the new clean needle. Interview on 08/21/24 at 12:22 P.M. with the Director of Nursing (DON) confirmed the expectation of the nurse was to prime the new needle applied to an insulin pen prior to each use. Review of the manufacturer's instructions for the Humalog insulin pen revised 07/2023 revealed the nurse should prime the insulin pen prior to each injection. Priming the pen meant removing air from the needle and cartridge that might collect during normal use and ensured that the pen was working correctly. If the nurse did not prime the pen before each injection there could be too much, or too little insulin administered. Review of the facility policy titled Medication Dispensing System undated revealed prior to medication administration the nurse should verify each medication to ensure that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer, and to verify that the MAR reflects the most recent medication order. Nurses should follow appropriate medication administration guidelines. Review of the policy titled Medication Errors Reporting - Pharmacy Related undated revealed errors included medications not administered within the allowed time frame, failing to administer an ordered dose, and administration of medication which was greater/lesser than what was ordered. Medication errors should be documented on an occurrence report. All medication incident reports would be reviewed by appropriate pharmacy and long-term care facility management to ensure the appropriate action was being consistently implemented. Review of the facility policy titled Emergency Pharmacy Service and Emergency Kits dated 03/28/18 revealed medications were only administered with a valid provider's order. A list of all medications and supplies were posted on the kit and system and should include medication, quantity, expiration date and the pharmacy name and phone number. A method of recording use of items from the emergency kit should be in place. Medications used from the emergency kit/system or entire kit shall be replaced.

Based on medical record review, review of the hospital history and physical, review of the hospital speech language pathology notes, surveyor observation, review of the facility census roster, interviews with facility staff, review of emails with the facility, review of the facility's elopement investigation, and review of the facility's policy on elopement, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at high risk for elopement from the facility and with a history of attempting to leave the facility, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #01 left the facility without staff knowledge and was found by an off-duty facility employee at a gas station 0.7 miles from the facility, having crossed a heavily traveled seven lane road in order to reach the gas station. This affected one (#01) of four residents (#01, #04, #06, and #08) reviewed for elopement. The facility identified two current residents (#01and #04) to be at risk for elopement. The facility census was 75. On 07/16/20 at 1:49 P.M., the Administrator was notified that Immediate Jeopardy began on 07/14/20 at 7:10 A.M. when Resident #01 was discovered by off-duty State tested Nurse Aide (STNA) #201 at a gas station near a busy intersection roughly 0.7 miles from the facility and located on the opposite side of the street. The gas station was located at an intersection with seven lanes of traffic and a speed limit of 40 miles per hour. Resident #01 had exited the facility through an unsecured window in the resident lounge into an enclosed courtyard and exited the courtyard via an unsecured and unalarmed gate. Resident #01 was hospitalized prior to admission to the facility after having been found wandering away from his home and identified as exhibiting exit seeking behavior in the facility. Resident #01 had not been observed by staff for approximately one hour prior to being found at the gas station by STNA #201. The Immediate Jeopardy was removed on 07/22/20 when the facility implemented the following corrective actions: · On 07/14/20 at 7:20 A.M., Resident #01 was returned to the facility and placed on one-on-one continuous staff observation. · On 07/14/20 at 7:20 A.M., Maintenance Director #204 initiated safety checks on all windows and doors on the Skilled Unit. The Skilled Unit resident lounge window was secured with new five-inch bolts which extended into the wooden window frame. · On 07/14/20 at 7:30 A.M., Unit Manager #205 completed a skin assessment on Resident #01 and no injuries were identified. · On 07/14/20, the facility began an investigation into Resident #01's elopement from the facility. · On 07/14/20 at 8:00 A.M., the Administrator and Unit Manager #205 began education with all staff regarding elopement policies and protocols. · On 07/14/20 at 8:00 A.M., the Administrator and Unit Manager #205 began education on Resident #01's care plan to all staff who work with the resident. · On 07/14/20 at 8:30 A.M., Maintenance Director #204 completed installation of new five-inch bolts on all windows in the Skilled Unit. The bolts were driven into the wooden window framing and prevented the windows from opening more than three and one-half inches. At 11:00 A.M., Maintenance Director #204 completed installation of the new bolts in all windows on the Program Unit, as well as in facility common areas. · On 07/14/20 at 9:30 A.M., the facility Quality Assessment Performance Improvement (QAPI) committee met to review Resident #01's elopement. · On 07/14/20, Maintenance Director #204 began daily visual checks of all windows and doors in the facility to ensure they remained secured. This continued through 07/22/20. · On 07/15/20 at 8:00 A.M., the Director of Nursing (DON) audited the Profile Form Notebooks for accuracy and updates were completed. The Profile Form Notebooks provide identification information for the residents at risk for elopement. · On 07/15/20 at 10:00 A.M., Resident #01 was assessed by the neurologist. The neurologist ordered changes to Resident #01's medications. · Observation of room windows on 07/15/20 ending at 10:54 A.M. revealed the windows in resident Rooms #120, #124, #129, #130, #131, #133, #136, #137, #140, and #141 were secured with longer bolts. · On 07/15/20 at 11:00 A.M., Maintenance Director #204 finished installing the new bolts on all office windows. · On 07/16/20 at 10:00 A.M., the DON, Unit Manager #205, and Unit Manager #250 completed audits of all resident elopement assessments and care plans. · On 07/17/20 at 3:00 P.M., the Administrator and Unit Manager #205 completed education to all staff on the facility elopement policies/protocols and on Resident #01's care plan for all staff who work on the Skilled Unit. · On 07/20/20 at 3:00 P.M., every 15-minute checks were initiated on the resident lounge areas. At this time, Unit Manager #205 began educating nursing staff on the 15-minute checks for safety of resident lounge area. · On 07/21/20 at 4:00 P.M., Maintenance Director #204 installed a temporary alarm on the courtyard exit gate. The alarm is audible on the Skilled Unit, which is closest to the courtyard gate. The facility has made arrangements for a permanent alarm to be installed that is audible throughout the building. · On 07/22/20 at 1:00 P.M., the Administrator began educating staff on duty on the Skilled Unit on the audible alarm located on the courtyard exit gate. Education was in person and via the telephone. The facility will continue to educate each staff member not already educated, prior to their shift until the permanent alarm is installed and an all staff in-service can be conducted. · The medical records for Resident #04 identified as the only other resident at risk for elopement, and for Resident #06 and Resident #08 were reviewed with appropriate assessments and plans of care in place. There were no other identified elopement events. Although the Immediate Jeopardy was removed on 07/22/20 at 3:00 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the medical record for Resident #01 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the hospital history and physical dated, 06/23/20, documented Resident #01 was admitted to the hospital on [DATE] after being found wandering at a gas station. Review of the hospital Speech Language Pathologist (SLP) note, dated 07/01/20, identified Resident #01 may take unsafe actions to address his needs independently. The note documented Resident #01 would benefit from one-on-one supervision due to impulsivity and poor safety awareness. Review of the nursing admission assessment, dated 07/10/20, revealed Resident #01 was able to understand others and make himself understood. Resident #01 was at risk for elopement and wandering; however, his wandering did not place him at significant risk of getting to a potentially dangerous place such as outside the facility. Resident #01 required supervision or touch assistance with walking 150 feet in a corridor or similar space. Review of the baseline care plan, dated 07/10/20, revealed Resident #01 had behaviors of wandering and exit seeking. The baseline care plan revealed Resident #01 was at risk for elopement and wandering. Interventions included the resident to be on a secure unit and the resident was allowed to have his door closed. The baseline care plan indicated Resident #01 had mild cognitive deficits and was independent with walking, transfers, bed mobility, and locomotion. Review of the elopement risk assessment, dated 7/10/20, revealed Resident #01 was not disoriented, was aware of his surroundings, had unsafe decision making capabilities, was exit seeking, had attempted to leave his home, was easily re-directed when wandering/exit seeking, was ambulatory, had a [DIAGNOSES REDACTED]. The interventions on the 7/10/20 elopement assessment included completion of a Profile Form and the resident was to reside on a secured unit. Review of the nurses' note, dated 07/10/20, revealed Resident #01 was alert to self. Review of the nurses' note dated 07/11/20 revealed as soon as Resident #01 wakes up he begins pacing up and down the unit looking for an exit, asking staff to let him out or call him a cab. Resident #01 was not able to follow instructions and could not be reassured. Review of the nurses' note dated 07/13/20 revealed Resident #01 continued to be exit seeking and restless. A second nurses' note dated 07/13/20 revealed Resident #01 was pacing up and down the unit and was exit seeking. Review of Certified Nurse Practitioner (CNP) #200's note, dated 07/13/20, revealed staff had reported Resident #01 was pacing and was exit seeking. Resident #01 was oriented times one and was confused. On 07/13/20, CNP #200 ordered the [MEDICAL CONDITION] medication [MEDICATION NAME] 250 milligrams by mouth, two times a day, for restlessness. Review of the Situation Background Assessment Recommendation (SBAR) communication form, dated 07/14/20, revealed Resident #01 was noted to be outside of the facility on 07/14/20. The resident was brought back to the facility and an assessment was completed. No injuries were noted. Upon notification to CNP #200 of the event, she recommended Resident #01 be placed on one-on-one staff supervision. Review of the elopement assessment, dated 07/14/20, revealed Resident #01 was no longer aware of his surroundings and had attempted to leave the facility. This was identified as a change from the last assessment. A new intervention identified Resident #01 was placed on direct one-on-one staff supervision. Review of Resident #01's baseline care plan revealed a new intervention was added on 07/14/20 to include a one-on-one staff supervision. Review of the facility investigation into Resident #01's elopement revealed on 07/14/20 at 6:00 A.M., while completing rounds, STNA #202 observed Resident #01 come out of his room and ambulate independently down the hallway. On 07/14/20 at 6:10 A.M., Licensed Practical Nurse (LPN) #203 was with Resident #01 for several minutes completing an assessment of him. After the assessment, LPN #203 went down the other hall on the unit while Resident #01 remained in the hallway. On 07/14/20 at 7:10 A.M., STNA #201 arrived at a gas station down the street from the facility and observed Resident #01 on the gas station property. At 7:15 A.M., STNA #201 called the facility charge nurse and reported Resident #01 was at the gas station. The nurse notified the Unit Manager and the Administrator. The Administrator and Unit Manager immediately went to the gas station, which was found to be 0.7 miles from the facility and drove Resident #01 back to the facility. On 07/14/20 at 7:20 A.M., Resident #01 returned to the facility and was placed on one-on-one staff supervision at all times. During an interview on 07/15/20 at 8:50 A.M., the Administrator and DON revealed the entire facility is a secured facility. The interview revealed Resident #01 was admitted to the facility due to his wandering behaviors while at home. The Administrator revealed Resident #01 exited the facility via the window in the resident lounge area on 07/14/20. The windows in the facility have bolts in place to prevent them from opening more than approximately three and one-half inches; however, Resident #01 removed the bolts from the resident lounge window, knocked the window screen out, and exited the facility. During the interview, the Administrator stated STNA #201 had clocked out after her shift ended at 7:00 A.M. on 07/14/20 and was on her way home from the facility when she stopped at the gas station and observed Resident #01. Observations of the Skilled Unit on 07/15/20 between 8:55 A.M. and 9:33 A.M. revealed the resident lounge was located next to the nurses' station and had one window that exited to an enclosed courtyard area. The resident lounge window was secured with bolts to prevent the window raising greater than approximately three and one-half inches. Observation on 07/15/20 at 9:16 A.M. revealed Resident #01 was lying in bed. A staff member was observed to be seated in a chair near the bed. During an interview on 07/15/20 at 9:16 A.M., Maintenance Director #204 revealed when he checked the resident lounge area window after Resident #01 was discovered to have left the facility, he found both of the bolts had been removed from the window frame, allowing the window to open all the way. Maintenance Director #204 revealed he also discovered room [ROOM NUMBER] and room [ROOM NUMBER] each had one bolt removed from the window frames. Review of the facility census revealed room [ROOM NUMBER] was occupied by Resident #01 and room [ROOM NUMBER] was vacant. During an interview on 07/15/20 at 10:10 A.M., Maintenance Director #204 revealed the window bolts in use on all the windows prior to Resident #01's elopement only went through the frame of the window and were not secured to any wall structure. The bolts were only three inches in length and rested into an air pocket between the aluminum window framing and the structural wooden window studs. Maintenance Director #204 stated the window bolts could have possibly been loosened by consistently being hit when residents attempted to open the window beyond the three and one-half inch gap. Maintenance Director #204 stated on 07/14/20 he replaced all the three-inch bolts with five-inch bolts that are secured into the structural wooden window studs. During an interview on 07/15/20 at 11:47 A.M., the Administrator verified facility staff were not aware Resident #01 was missing and had eloped until they received a call from STNA #201 on 07/14/20 at 7:15 A.M. stating she was with Resident #01 at a gas station. The Administrator also verified the facility staff were aware Resident #01 exhibited exit seeking behaviors at home. During an interview on 07/15/20 at 2:37 P.M., the DON stated when a resident was at risk for elopement, resident specific interventions are to be put into place. The DON revealed the interventions in place for Resident #01's elopement risk included the secured unit and a Profile Form. During an interview on 07/15/20 at 3:57 P.M., STNA #201 revealed she was on her way home from work on 07/14/20 when she stopped to get gas at the gas station and noticed Resident #01. She stated Resident #01 was wearing a short-sleeved shirt, shorts, and shoes when she saw him. She stated she approached him, and he told her he had left the facility, did not tell the facility he left, and did not want to go back to the facility. STNA #201 stated she called the facility staff to notify them Resident #01 was at the gas station and she stayed with Resident #01 until facility staff arrived to pick him up. Review of e-mail correspondence with the Administrator, dated 07/15/20 at 4:38 P.M. and 4:48 P.M., revealed when Maintenance Director #204 observed the resident lounge window on 07/14/20, the bolts preventing the window from opening greater than three and one-half inches were removed. One of the bolts was found on the ground while the other was found on the windowsill. During an interview on 07/16/20 at 8:01 A.M., LPN #203 stated she saw Resident #01 pacing up and down the hallway on 07/14/20 between 5:00 A.M. and 6:00 A.M. She took Resident #01's blood sugar around 6:00 A.M. and then went to the other side of the unit. She gave report to the on-coming nurse around 7:00 A.M. LPN #203 stated she did not see Resident #01 after 6:00 A.M. She stated she had never observed Resident #01 messing with the windows prior to 07/14/20; however, she had heard of other staff who saw him trying to open the windows on the unit. She had not heard of him trying to remove the bolts of the window. LPN #203 did verify Resident #01 was known to exhibit exit seeking behaviors. During an interview on 07/20/20 at 8:23 A.M., the Administrator stated the resident lounge window that had been tampered with opens to an enclosed outside area. There is a gate in the enclosed outside area Resident #01 had to go through to leave the facility property. The Administrator stated the gate is neither locked nor alarmed. During an interview on 07/20/20 at 9:45 A.M., Unit Manager #205 revealed she arrived to work on 07/14/20 between 6:00 A.M. to 6:30 A.M. Unit Manager #205 indicated she had no knowledge Resident #01 had left the building when she arrived at the facility. She was made aware Resident #01 had eloped a little after 7:00 A.M. During an interview on 07/20/20 at 12:08 P.M., Registered Nurse (RN) #206 stated LPN #203 gave her report on 07/14/20 at 7:00 A.M. At that time, she was unaware of Resident #01 having left the facility. She stated once she became aware of Resident #01 having left the facility, she observed the resident lounge window and it was closed but looked like it had been manipulated. Review of e-mail correspondence with the Administrator, dated 07/20/20 at 12:15 P.M., revealed the gate to the enclosed courtyard outside the resident lounge window was closed when Maintenance Director #204 observed it on 07/14/20 after being notified Resident #01 had left the facility property. Review of the undated facility policy titled Elopements and Wandering Residents revealed the facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Residents will be assessed for risk of elopement and unsafe wandering upon admission and during their stay by the interdisciplinary team. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. Charge nurses and Unit Managers will monitor the implementation of interventions, response to interventions, and document accordingly. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to staff. This deficiency substantiated Complaint Number OH 091.

Based on medical record review, observation, policy review, and staff interviews, the facility failed to ensure residents were free from involuntary seclusion. This resulted in Immediate Jeopardy for 44 cognitively impaired residents residing in rooms with doors that locked from the outside when the doors were closed (Resident #4, #5, #15, #16, #19, #24, #28, #36, #38, #39, #41, #42, #43, #49, #51, #52, #53, #58, #60, #62, #63, #66, #67, #69, #75, #80, #82, #83, #86, #87, #88, #91, #94, #95, #99, #100, #102, #103, #105, #107, #108, #117, #118 and #500). This involved 23 of 62 rooms in the facility. The facility census was 99. The Administrator was notified that Immediate Jeopardy began on 07/17/13 at 11:51 A.M. when Resident #53's door to his room was observed to be locked from the outside and a family member opened the door from the outside with a key. The resident was blind and severely impaired for daily decision-making and was observed alone in the room when the door was opened. The call light system was disabled. The call cord was removed and the access port was capped. The Immediate Jeopardy also affected 43 additional cognitively impaired residents residing in rooms with doors locked from the outside when the door was closed. The call light system in these rooms was disabled. The facility removed the call cords and capped off the access ports. No alternate means of summoning help was provided. These 43 residents were identified to be moderately to severely impaired for daily decision-making skills. The Immediate Jeopardy remains ongoing due to the locked resident room doors, failure to provide staff training and frequency of supervision of these residents, the facility had no documented criteria to determine which resident was to be placed in a room with doors equipped to lock from the outside, the lack of completed comprehensive assessments of each resident's ability to exit a room that was equipped to lock from the outside, rooms were not equipped with a functional call light system, and no other system was in place to notify the staff in the event of an emergency. Findings include: 1. On 07/17/13 at 11:51 A.M., Resident #53's spouse was observed using a key to gain entrance to the resident's room. Resident #53's spouse verified at that time the door was locked from the outside. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was severely impaired for daily decision-making, required extensive assist with bed mobility, transfers, toilet use, personal hygiene and required limited assist with walking in the room/corridor. Review of the Care Area assessment dated [DATE] revealed Resident #53 was unable to make his needs or wants known. On 07/18/13, observations of Resident #53 revealed the following: At 7:30 A.M., State tested Nurse Aide (STNA) #75 stated the resident was in his room. STNA #75 placed a key in the resident's door and Resident #53 was observed sitting on his bed, dressed and wearing gripper socks. STNA #75 stated she would take the resident out of his room closer to breakfast time because they did not want the residents "just walking around and going into other resident rooms". STNA #75 left the resident sitting on his bed and closed the door. The door locked behind her. An interview with STNA #75 verified Resident #53 was in his room and the door was shut and locked from the outside. STNA #75 stated some resident doors had locks and some resident's doors did not. STNA #75 was not aware of how it was determined which resident had a door that locked and who did not. STNA #75 stated the doors that locked kept residents from wandering into other residents' rooms. At 7:45 A.M., Resident #53's room door was opened and he was observed ambulating in his room. Licensed Practical Nurse (LPN) #6 walked hand-in-hand with Resident #53 out of his room into the living area. At 9:54 A.M., Resident #53 was observed ambulating independently around residents seated in a circle in the middle of the living area listening to a trivia activity. Resident #53 was not being supervised by staff. Resident #53 walked into the utility hallway and began banging on the door stating "Help, Help". Resident #53 put his hands out in front of him and was feeling objects as he walked. The resident walked toward the middle living area where other residents were listening to trivia with Activity Director (AD) #3. AD #3 was standing in the middle of the circle created by the residents seated in chairs. Resident #53 walked through the circle of residents and AD #3 continued to read the trivia activity to the other residents. At 10:48 A.M., AD #3 was observed to ambulate Resident #53 back to his room. At 10:49 A.M., AD #3 was observed to exit the resident's room and shut the door. The door locked behind her. The resident remained in the room alone and without a call cord. On 07/20/13, observation of Resident #53 revealed the following: At 10:03 A.M., Resident #53 was not observed in the living/dining area on the programming unit. At 10:10 A.M., an interview with STNA #45 verified Resident #53 was not in an activity and STNA #45 she had not seen the resident while assisting residents to the living/dining area since before the bowling activity started. STNA #45 stated "he is probably in his room". At 10:13 A.M., STNA #45 walked toward Resident #53's room, took a key out of her pocket, unlocked the resident's door and observed Resident #53 ambulating around his room with his arms in front of him outstretched. STNA #45 verified the outside door handle to the resident's room was locked whenever the door was closed and required a key to gain entry. STNA #45 verified there was no staff in the room with the resident and was aimlessly walking in the room, in silence. At 10:24 A.M., interview with STNA #45 verified Resident #53 was unable to open the door from the inside to exit his room. At 10:30 A.M., STNA #45 stated she was unaware why Resident #53 was in his room with the door shut. At 10:32 A.M., STNA #45 opened the door to Resident #53's room and guided the resident to the threshold of the door. Resident #53 then ambulated into the living area. At 10:34 A.M., Resident #53 was observed ambulating in the living area of the programming unit without supervision and entered Resident #38's room. At 10:36 A.M., an activity aide walked past Resident #38's room, saw Resident #53 and stated "that is not your room" and continued to walk another resident to an activity. At 10:37 A.M., AD #3 was observed entering Resident #38's room and told Resident #53 "come with me". AD #3 grasped Resident #53's left hand, led him out of Resident #38's room and walked with him hand-in-hand across the living area. There was no conversation observed between AD#3 and Resident #53 as they walked across the living area and into Resident #53's room. At 10:38 A.M., AD #3 was observed guiding the resident to sit on the bed. At 10:39 A.M., AD #3 left Resident #53's room, and shut the door. The resident's door locked behind her. At 10:40 A.M., the surveyor attempted to open the resident's door and the door was locked. AD #3 walked back to the middle of the main living area and began watching the golf activity with other residents. Interview with AD #3 verified she walked the resident to his room, left the room and shut the door. AD #3 stated the resident indicated he wanted to lie down so she put him in his room. At 10:42 A.M., Resident #53's spouse arrived on the unit, asked where Resident #53 was and the staff informed her he was in his room. Resident #53's spouse walked toward the resident's room, pulled out a key, put the key in the door handle lock and opened the resident's door. The resident was observed standing in the middle of the room reaching out toward the wall. At 10:43 A.M., Resident #53's spouse asked the resident if he wanted to lie down and the resident said "No, why would I want to lay down" and continued to walk in the room toward her. The resident's spouse asked Resident #53 what was wrong and the resident stated he needed to go to the bathroom. At 10:44 A.M., observation revealed STNA #46 entered Resident #53's room to assist STNA #61. STNA #46 verified Resident #53 was incontinent of bowel. On 07/18/13 at 10:53 A.M., the Dietary Manager was observed attempting to open Resident #53 ' s locked door. The Dietary Manager did not have a key and was observed walking to the nurse ' s station to obtain the key. 2. Review of the facility ' s Admission to the Secured Dementia Unit (dated October 2010) revealed all residents had to have a primary [DIAGNOSES REDACTED]. As a consequence of this disease process, the resident's safety awareness was altered, rendering the resident unable to make safe decisions with regard to leaving the facility unassisted. Review of the facility's Admission Packet revealed no mention residents may be placed in a room with doors equipped with a lock. Review of the Abuse, Neglect, Misappropriation and Injury of Unknown Source policy (dated October 2012) revealed residents had the right to be free from physical, verbal, sexual, mental abuse, misappropriation of property, corporal punishment and involuntary seclusion. Review of the Evacuation Plan policy (undated) revealed no documented evidence of a procedure for evacuation of residents residing in rooms with doors equipped to lock from the outside. Review of the Safety Door Lock policy (dated October 2012) revealed safety locks, sometimes known as " pop " locks, may be used based on the needs of the resident with input from the family/responsible party. Reasons these devices are used include higher functioning residents who may request a lock for the purpose of personal security or territorial residents who may be at increased risk to cause harm to a peer secondary to a peer wandering into their room. At times, a safety lock may be needed to secure resident belongings or equipment. Review of the Medical Director (MD) Agreement (dated 02/01/13) revealed the medical director was to provide care services and was responsible for assisting in the development of administrative regulations. On 08/05/13, the facility identified 23 of 62 resident rooms, with 44 residents residing in the rooms, that had doors equipped to lock from the outside. The rooms did not have a call light system and the locks on the resident doors did not release with the fire alarm. On 08/05/13 at 8:19 A.M., an interview with Registered Nurse (RN) #21 revealed residents with a lock on the door had to be able to locate their room, notify a nurse if they lost their key and be able to open the door with a key. RN #21 stated if the resident met these criteria and the family wanted them to have a room with a lock, they were given one. RN #21 stated in an emergency, residents were evacuated room by room; everyone in the facility had assigned places and if an alarm sounded staff would go to that area. RN #21 stated any key opens the doors, and they were locked to keep other residents out of the rooms. Review of a posting taped to the Programming Unit nurse ' s station revealed a list of residents residing in the facility who could have the door to their room closed when they were in their room alone. The list included Residents #19, #36, #39, #51, #52, #63, #69, #82, #91, #94, #105, #107, #108 and #118. On 08/05/13 at 8:57 A.M., an interview with RN #21 verified the above residents resided in rooms with doors that locked from the outside when the door was closed. Review of in-service training revealed the facility ' s last specialized training on Behavior-Dementia and Alzheimer ' s was dated 09/25/12. The training addressed behaviors of residents and did not address the needs of secluded residents in locked rooms. On 08/05/13 at 8:30 A.M., interview with Maintenance Director #89 stated Residents #4, #5, #15, #16, #19, #24, #28, #36, #38, #39, #41, #42, #43, #49, #51, #52, #53, #58, #60, #62, #63, #66, #67, #69, #75, #80, #82, #83, #86, #87, #88, #91, #94, #95, #99, #100, #102, #103, #105, #107, #108, #117, #118 and #500 resided in rooms with doors that locked from the outside when the door was closed. Review of the list of residents utilizing a Broda or a Geri chair (specialized reclining wheelchairs) provided by Employee #114 revealed four residents (Residents #5, #28, #42 and #500) used a reclining wheelchair and also had a lock on their door. On 08/05/13 at 8:58 A.M., an interview with Licensed Practical Nurse (LPN) #11 revealed some residents had rooms with locks on the doors and stated it was a " pop " lock and that any key would open the lock from the outside. LPN #11 stated residents with a " pop " lock can open the door from inside the room at all times in order to get out of the room. LPN #11 stated some of the residents were high functioning and wanted their privacy and wanted to keep the residents from wandering into their room. LPN #11 stated other residents become upset when residents wander into their rooms. LPN #11 stated there were two nurses and five aides to care for 60 residents and it was not physically practical to try to keep the wandering residents out of the other rooms with these staffing ratios. LPN #11 stated in order to keep residents from wandering in and out of rooms, the facility would have to do one-on-one supervision with all the residents and " that was not going to happen " . LPN #11 verified the facility does not have enough staff to ensure residents do not wander into other resident rooms with door locks and the door locks provide that assurance that others do not enter the rooms. On 08/05/13 at 9:35 A.M., interview with Administrator #59 revealed door handles on some of the resident rooms required a key to enter the room to keep other residents from entering. On 08/05/13 at 9:46 A.M., an interview with Maintenance Director #89 stated as the door handles needed replaced, they were being replaced with a " pop " lock handle that required a key. Eventually, every resident room would have a locked door. Observation of the new door handles revealed a label that stated the door handles were privacy locks and the last order was received on 05/31/13. On 08/05/13 at 11:00 A.M., observation of Resident #4, #5, #15, #16, #19, #24, #28, #36, #38, #39, #41, #42, #43, #49, #51, #52, #53, #58, #60, #62, #63, #66, #67, #69, #75, #80, #82, #83, #86, #87, #88, #91, #94, #95, #99, #100, #102, #103, #105, #107, #108, #117, #118 and #500 ' s rooms revealed the doors were equipped to lock from the outside. On 08/05/13 from 12:00 P.M. through 1:35 P.M. interviews with 15 residents residing in rooms with doors equipped to lock from the outside (Residents #4, #19, #49, #52, #58, #63, #66, #80, #82, #91, #99, #102, #103, #118 and #500 ) revealed each resident was severely confused, unsure if the doors were locked, if they had a key or if a key was needed and the residents were unable to indicate the location of their rooms. On 08/05/13 at 1:35 P.M., an interview with RN #21 verified the residents did not have a functioning call light system. RN #21 kept a key in her pocket and unlocked multiple rooms for the surveyor to enter and interview residents. Some residents were called to open the door from the inside, but did not respond to the nurse at that time. RN #21 verified " some " of the resident ' s doors should be left open but she indicated " We are a different kind of facility. " On 08/06/13 at 10:15 A.M., during an interview with the Regional Director of Operations (RGO) #112, RGO #112 provided the surveyor with a copy of a new Safety Door Lock Evaluation (dated August 2013) and verified the facility did not have a comprehensive assessment for the safety doors prior to initiation of this new assessment. RGO #112 stated all residents were reassessed on 08/05/13 using this new assessment. Surveyor requested a copy of the assessments completed at the time notified and as of 3:27 P.M. no assessments had been provided for review. On 08/06/13 at 4:10 P.M., RGO #112 provided surveyor with safety door lock evaluations. Residents continued to have locks on their room doors. On 08/06/13 at 11:44 A.M., interview with MD #126 revealed he was involved in the implementation of the policies and procedures at the facility and was responsible for all clinical and medical care at the facility. MD #126 stated he was the primary physician for 61 of 99 residents residing in the facility and verified residents residing in the facility due to the nature of their dementia disease process were confused. MD #126 stated the purpose of locking a dementia resident ' s door was an option for privacy due to many residents wander and get into other resident ' s personal space. MD#126 was not sure if residents were assessed prior to being placed in a room with a lock on the outside. MD #126 stated residents should be able to open the door from the inside if they had a lock on the outside of their door. MD #126 also stated he was aware residents did not have access to call lights in their rooms and stated if the resident had some understanding of the use of a call light, they should have one; however, if the resident had no understanding of the use of a call light, the call light cord posed a greater risk for the resident. MD #126 stated his expectations for supervision of residents without a call light included routine checks. The surveyor asked MD #126 to define how often " routine checks " should be done and he repeated " routine checks " . MD #126 stated he was aware resident room doors were equipped with a lock from the outside that were used to keep residents from wandering into other rooms and verified it was possible for some residents to be able to utilize a call light or door knob sometimes and the next time be unable to do so.

Based on observation, review of medical record, review of facility policy, interview of the Certified Nurse Practitioner (CNP) and staff interview, the facility failed to ensure provision of care and treatment to prevent the development of a pressure sores and provide care to promote the healing of a pressure sore. This affected one of one resident reviewed for pressure sores (Resident #16). The facility identified three residents in the facility with pressure sores. The facility census was 99. Harm occurred when Resident #16 who was admitted to the facility free of pressure sores and developed a Stage II (Partial thickness loss of dermis; shallow crater with pink wound bed area) pressure area (opened blister) after 31 days of admission to her left heel. The pressure area progressed within 22 days to an unstageable (Full thickness loss in which the base of the ulcer is covered by slough and or eschar /dead tissue in the wound bed). Findings include: Review of the medical record for Resident #16 revealed she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) Cognition score of three which indicated she was severely cognitively impaired. The MDS for the resident identified she required the extensive assistance of one person for the activities of daily living (ADL's) for bed mobility, transfers, dressing, toilet use and personal hygiene. She required limited assistance of one person for the ADL eating and supervision for walking in her room and corridor on and off the unit with a walker. The MDS identified she had no pressure area on admission and had a pressure reducing device for her chair and bed. Review of Resident #16's physician's orders [REDACTED]. The orders identified she would receive Hospice services due to end stage Alzheimer ' s disease and receive the medication of [MEDICATION NAME] 5 milligrams (mg) sublingual every four hours as needed for pain. Review of the June 2013 physician orders [REDACTED]. The June 2013 physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #16 received the [MEDICATION NAME] 5 mg's one time on 06/09/13, one time on 06/11/13, three times on 06/18/13, two times on 06/19/13, five times on 06/20/13, three times on 06/22/13 - 06/24/13 and twice on 06/26/13 and 06/27/13. The order was identified as discontinued on 06/27/13. The MAR indicated [REDACTED].M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. Review of the Plan of Care for Resident #16 revealed a care plan initiated on 07/17/13 identified the resident was at risk for skin breakdown over high risk area (i.e. coccyx, heels, etc). It identified her risk factors were associated with her disease process, her incontinence, her motor agitation, restlessness and mobility deficits. Intervention listed was to assist with turning and positioning with hands on as needed. A wound care plan for a wound on Resident #16's left heel was created on 07/17/13 and revealed the wound developed from repeated removal of her shoes and rubbing her foot on the carpet/floor. An intervention on the care plan was to see the behavior care plan. The behavior care plan was created on 06/04/13 and was revised on 07/18/13 identified the interventions did not include a specific behavior of Resident #16 repeatedly taking her shoes off and on and rubbing her feet on the carpet and what to do if the resident was noted doing this behavior. Review of the Braden Scale for Predicting Pressure Score Risk for Resident #16 revealed she was assessed on admission 05/21/13 with a score of 16. A score below 12 indicated a resident was at high risk for developing pressure area. A score between 15-18, indicated low risk for pressure sore development. She was assessed on 05/28/13 with a score of 17, on 06/04/13 her score was 18 and on 06/11/3 with a score of 17. On 06/25/13, the day the ulcer to her left heel developed she was assessed and scored a 17. Review of the Treatment Administration Record (TAR) for July 2013 revealed an order to monitor opened blister to left heel every shift and was initialed daily every shift that it was completed. An order to avoid shoes until left heel was healed. An order to cleanse left heel with normal saline apply calcium alginate and dry dressing every day and as needed. The order was discontinued on 07/03/13. an order for [REDACTED]. Elevate heels while in bed, skin prep to right heel, boot to left heel and check placement every shift. On 07/03/13 an order to cleanse left heel with normal saline and apply Santyl, Calcium Alginate and dressing and change every day the order was discontinued on 07/17/13. On 07/18/13, an order was started to cleanse left heel with normal saline apply crushed [MEDICATION NAME] 500 mg on top of the Santyl, apply closest to the wound bed. Review of the Skin Grid for Resident #16 revealed a Stage II pressure ulcer to Resident #16's left heel had been initiated on 06/25/13 and measured 3.0 centimeters (cm) by 3.0 cm with no depth. On 06/27/13 the pressure ulcer was identified as Stage II and measured 2.3 cm by 3.0 cm with less than 0.1 cm depth. the area had serosanguinous drainage and was beefy red in color, no odor was identified. On 07/03/13, the wound had declined to an unstageable area and measured 2.5 cm by 2.5 cm with 0.1 cm depth. The assessment revealed the wound had 50 percent slough with mild odor. On 07/10/13, the wound was identified as a Stage III and measured 2.2 cm by 2.4 cm and had a depth of 0.1 cm. The color was dark red and slough was noted. The wound had a mild odor and was noted to have been tender. On 07/17/13, the wound was unstageable and measured 3.3 cm by 4.4 cm with purulent drainage. The color was eschar with mild odor. Review of the Nurse's Notes for Resident #16 revealed on 06/25/13 a Hospice aide was bathing the resident and reported to the nursing staff an opened blister that measured 3.0 cm by 3 cm to her left heel. The Power of Attorney (POA) was notified and stated the resident was known to wear two pair of shoes daily. The POA stated she had noticed minor swelling the week prior and stated the resident's shoes were too tight. Review of Resident #16's Progress Notes revealed a history and physical (H&P) completed by the Medical Doctor (MD) on 05/23/13 and revealed she was admitted to Hospice care, had failure to thrive and was to continue current medications, her skin was warm and dry. The H&P did not identify any skin breakdown. Review of a written statement dated 07/18/13 from the Certified Nurse Practitioner (CNP) revealed Resident #16 would stand/sit constantly, take shoes on and off. She noted in the statement the pressure ulcer on Resident #16's left heel was a result of her severe agitation, taking her shoes on and off and using her heels as leverage to scoot in the bed. On 07/18/13 at 7:36 A.M., observation of Resident #16 revealed the resident was in bed turned slightly to the right and had moon boots to heels. Heels were not elevated off of the bed as ordered. . On 07/18/13 at 9:09 A.M., interview with State tested Nurse Aide (STNA) # 35 verified Resident #16 was in bed with heel protectors on one foot and her heels were not elevated off of the mattress. On 07/18/13 at 10:53 A.M. observation of Resident #16 revealed Licensed Practical Nurse #50 (LPN) completed a dressing change to her left heel. LPN #50 identified the left heel as an unstageable area to the left heel covered with eschar tissue in the wound bed and measured 3.9 cm by 4.4 cm with 0.1 cm depth. The area had no drainage and a mild odor was noted. On 07/18/13 at 10:53 A.M. during the dressing change observation revealed Registered Nurse (RN) #114 entered the resident's room and stated her tennis shoes caused the pressure area. She stated the resident would constantly slide the shoes on and off her feet all the time. On 07/18/13 at 10:53 A.M. during the dressing change, an interview with LPN #6 verified the resident had motor agitation and she had two pair of shoes and she would take her shoes on and off, on and off constantly over and over. She also stated the daughter told the staff the resident had [MEDICAL CONDITION]/swelling and she could not remember if she had told them before or after the pressure ulcer had developed. On 07/18/13 at 11:24 A.M. interview with Certified Nurse Practitioner (CNP) verified Resident #16's pressure ulcer was from the shoes she wore being repeatedly slid off and on the resident's heel. The CNP stated the resident was extremely motor agitated for awhile and it was reasonable to say that her slipping her shoes on and off constantly could have caused the pressure ulcer to her left heel. On 07/18/13 at 2:40 P.M. interview with STNA #35 stated Resident #16 was not ambulatory now she stated she did not know why. She stated two weeks ago Resident #16 was in a wheelchair and is now in high back wheelchair. She stated the resident would constantly take her shoes off and on she stated she had an infatuation with shoes and even socks. She revealed the she did not have anything special to do for the resident when she would take her shoes off and on. She stated it was probably because she walked then. She was always fidgeting. On 07/18/13 at 2:52 P.M. interview with LPN # 11 verified there was no actual care plan or intervention for Resident #16. He stated the only thing the staff could do was try traction socks. He stated the resident just had a fidgety behavior and slipping her shoes on and off was what she did. On 07/18/13 at 3:07 P.M. interview with LPN # 6 verified there was no behavior care plan for the resident regarding the behavior of taking her shoes off and on. She stated when the resident was taking her shoes off and on she felt it was a fidgety thing. She stated if she would take them off we would try to grab the shoes. She stated it is just something she would do, she did it a lot especially when she was in activities. She stated there was no behavior program for the sock and shoes being taken on and off an investigation was not done to determine the cause of the pressure ulcer to Resident #16's left heel. She also stated there were no interventions defined anywhere. LPN #6 then stated she would sometimes take other clothing items off and everyone would just help put it back on. She could not remember if Resident #16 was high risk for pressure when she was admitted she stated she would have to look at her Braden scale to see if she was scored as high risk. Review of the facility's Wound Prevention and Treatment Policy dated 08/30/12 revealed the facility strives to ensure a resident entering the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. The goal of treatment is to promote healing, prevent any complications, prevent deterioration, and minimize any harmful effects to both the wound and overall condition of the resident. Identified on this policy under turning and positioning is to evaluate bed mobility and develop a resident specific turning schedule based on identified risk and tissue tolerance. Individualized positioning regime and repositioning schedule will be documented and may be displayed per individual facility standard so as to not to violate Resident Rights. Completely relieve heel pressure when in bed. Support length of legs with a pillow. Physical or Occupational Therapy may be contacted for heel positioning devices. The policy also identified to protect elbows and heels if being exposed to friction (i.e. transparent films, socks, pillows, foam blocks, heel booties, etc.).

Based on clinical record review, review of a self reported incident, observation, staff and resident interviews, and policy review, the facility failed to protect one resident from abuse resulting in harm. The resident alleged and the facility substantiated that State tested Nursing Assistant #100 slapped her left cheek and squeezed her right hand hard resulting in a five centimeter bruise on her hand. This affected one resident (#61) of four sampled residents. The facility census was 99. Findings include: Clinical record review revealed the Resident #61 was admitted to the facility on [DATE] and was [AGE] years old. Her cumulative [DIAGNOSES REDACTED]. Her medications included an antidepressant ([MEDICATION NAME]), three psycho-active medications ([MEDICATION NAME] , [MEDICATION NAME] ER and [MEDICATION NAME]), an anti-anxiety ([MEDICATION NAME]), and two blood thinning medications ([MEDICATION NAME] and baby Asprin). The resident's Minimum Data Set Assessment, dated 10/08/10, revealed she scored 14 out of 15 on the cognitive. She usually understood questions. She required the assistance of one or two staff for her care needs and required a Hoyer lift for bed to chair transfers. Her diet order, dated 10/13/10, was pureed with honey thickened liquids. She required spoon feeding at meals. A nursing note from Licensed Practical Nurse (LPN) #200, dated 11/20/10 at 9:00 A.M., revealed Resident #61 left cheek had a slight discoloration (which did not bruise) under her left eye. The nurse noted she was uncertain if there was trauma to the left eye area. In addition, the resident had slight [MEDICAL CONDITION] with discoloration on her right hand. The resident could move her right hand digits freely. The resident complained of pain only if the right hand was touched. A social services note, dated 11/23/10, revealed the resident stated she was not distressed and did not fear for her safety. An X-ray of the resident's right hand, dated 11/23/10, revealed some [MEDICAL CONDITION] arthritic changes with no evidence of a fracture or dislocation. The physician's note, dated 11/23/10, revealed the Resident #61 's right hand had ecchymosis over the dorsal knuckles, particularly the index finger with hematoma. Review of a self reported incident, dated 11/20/10 at 9:00 A.M., revealed State tested Nursing Assistant (STNA) #200 observed ecchymoses from the SR's right thumb, across the back of her right hand ending at the fifth finger. Resident #61 told STNA #200 the aide who had cared for her the evening before (STNA #100) slapped her left cheek and squeezed her right hand too hard because she called him an offensive name and made him mad the night before (on 11/19/10). Licensed Practical Nurse (LPN) #200 examined the resident on 11/20/10 at 9:00 A.M. and documented a five centimeter bruise across the diameter of the SR' s right hand; however, there was only a slight discoloration on the right corner of her eye. The facility conducted an investigation and substantiated STNA #100 squeezed Resident #61's hand too hard and caused the large bruise. STNA #100 was suspended on 11/20/10 and denied slapping or squeezing the resident's hand when the Director of Nursing interviewed him. STNA #100's statement revealed on the night of 11/19/10, the resident was mad about getting out of bed for supper and was also angry when he served her honey thickened water instead of the thin water she preferred. The resident called STNA #100 a liar about having three wives and called him an offensive name. STNA #100 reported a small bruise on the SR's right hand to his nurse (LPN #10) when he completed the resident's incontinence care (by himself) on 11/19/10 at around 10:00 P.M. The Director of Nursing terminated STNA #100 on 11/23/10 because the facility substantiated the abuse allegation. The surveyor observed Resident #61 right hand on 11/24/10 at 1:50 P.M. which revealed a black purple bruise encompassing the entire top of the hand, extending up all four fingers with the outer edges of the bruise yellow. The surveyor interviewed the resident at that time who stated somebody hurt my hand. She stated " He wanted me to go to the dining room and I did not want to go. He slapped me across the face and squeezed my hand very hard." Resident #61 stated she had called STNA #100 an offensive name. Interview with the Administrator and Director of Nursing on 11/26/10 at 1:35 P.M. revealed the abuse incident most likely occurred on 11/19/10 between 5:00 and 10:00 P.M. There were no eye witnesses to the incident. There was a statement from LPN #10 who worked the evening shift on 11/19/10 which revealed she saw no bruise at 10:15 P.M. on the resident's right hand, only a small discolored area. The resident told LPN #10 nothing happened at that time. The resident did not accuse STNA #100 of slapping her and squeezing her hand until 11/20/10 at 9:00 A.M. when she made this statement to STNA #200. The Director of Nursing felt STNA #100 did not tell the truth when he stated he did not squeeze Resident #61's hand. Interview with the Director of Nursing revealed she substantiated abuse and did not consider the incident involving the STNA #100 and Resident #61 an injury of unknown origin because the resident repeated the same consistent story over and over accusing the STNA #100 of slapping her cheek and squeezing her hand (abuse). According to the Director of Nursing, Resident #61 did not accuse any resident or staff member of abuse prior to this incident on 11/19/10. Interview with STNA #200 on 11/26/10 at 2:20 P.M. verified she first noticed the large bruise on Resident #61' s right hand on 11/20/10 at 9:00 A.M. and reported the finding to LPN #200 immediately. Interview with LPN #200 on 11/26/10 at 2:30 P.M. verified she did not see anything indicating the Resident #61 was slapped on the cheek; however, she observed the five centimeter bruising on the top of the resident's right hand on 11/20/10 at 9:00 A.M. and notified the resident's physician and daughter. During an interviewed with STNA #100 by phone on 11/30/10 at 10:45 A.M. he stated he did not slap Resident #61 face or squeeze her hand too hard. STNA #100 stated the evening of 11/19/10 the resident called him a "liar" when he told her he did not have three wives. He stated she was mad at him when he got her up for dinner and served her honey thickened liquids. He stated on 11/19/10 around 10:00 P.M. when he provided incontinence care he noticed the resident was rolled over near the wall and had a blue, quarter size bruise on the back of her right hand. He reported the bruise to LPN #10 and stated he did not know how the bruise happened. During an interviewed with Resident #61 on 12/06/10 at 10:00 A.M, the surveyor asked if anyone ever hurt her. The resident stated "Do I have to go over that again. A man named (STNA #100's name) hurt my hand". Interview with Resident #61' s daughter on 12/06/10 at 1:25 P.M. revealed the resident had a stroke [AGE] years ago which changed her mother dramatically. The past [AGE] years, her mother was blind in the left eye and paralyzed on the left side, and totally dependent on others for her care. Her mother had no patience with the staff and would scream because her body was stiff when they touched her to provide care. Review of the facility policy regarding abuse, dated 11/09, revealed abuse was the willful infliction of injury resulting in physical harm, pain or mental anguish. This federal citation substantiates an allegation contained in the Self Reported Incident Number OH 559.